CCM Care Plan Template: What CMS Expects in Each Plan

Use this CCM care plan template to build an electronic, patient-centered comprehensive care plan for each CCM patient (MLN909188). Brackets mark fields to complete; the billing practitioner sets the clinical content.

If you need a chronic care management template PDF for training, print the table below; the finished plan itself is electronic (MLN909188).

The chronic care management care plan template, row by row

This CCM template copies into your EHR’s care plan form row by row; brackets mark what your team fills in.

Plan section	Complete for this patient
Plan header	[Billing practitioner; consent date; date plan established]
Patient record	[Demographics; problems; medications; medication allergies in structured EHR fields; date checked]
Assessment	[Physical: finding, date, assessor]; [mental: finding, date, assessor]; [cognitive: finding, date, assessor]; [psychosocial: finding, date, assessor]; [functional: finding, date, assessor]; [environmental: finding, date, assessor]
Resources and supports	[Caregiver assessment and role; resources and services in place; gaps]
Problem list	[Each chronic condition the plan manages]
Patient priorities	[What matters most to the patient, in their words; date asked]
Outlook	[Expected outcome and prognosis, stated by practitioner]
Goals	[Condition; measurable treatment goal; measure; baseline; target date; review date; set by practitioner]
Symptoms	[Condition; symptom management; what to watch for; whom to contact]
Care team and access	[Designated care team member and role; how to reach the practice for urgent needs 24 hours a day, 7 days a week]
Interventions	[Condition; planned intervention; medical management; owner; due date]
Medications	[Review and interactions; oversight of self-management; review date; reviewer]
Preventive services	[Recommended service due; date arranged]
Coordination	[Outside practitioner, agency or resource; role; last exchange; continuity-of-care documents shared]
Copies	[Shared within/outside practice; patient/caregiver copy when necessary; recipient; format; date]
Review	[Review date; established, implemented, revised or monitored; change made; approved by]

CCM care plan template requirements to meet first

Settle three things before the first entry.

• Eligibility and consent. The patient needs two or more chronic conditions expected to last at least 12 months or until death, with significant risk of death, acute exacerbation or decompensation, or functional decline (MLN909188). Document consent before CCM starts; CCM eligibility and consent covers both.
• An initiating visit, where required. New patients, and patients the billing practitioner has not seen within the previous year, need an initiating visit at which CCM is discussed (MLN909188).
• A billing practitioner who owns the plan. The clinical calls in it are theirs: CMS says the practitioner’s oversight, management, collaboration and reassessment cannot be delegated (CMS CCM FAQ).

How to build a CCM care plan in seven steps

Step 1: Record the core data in certified EHR technology

Rule: demographics, problems, medications and medication allergies are recorded in a certified EHR version acceptable under the EHR Incentive Programs as of December 31 of the year before the payment year (MLN909188). Do: confirm the four fields are structured entries, not lines in a scanned note.

Step 2: Assess all six domains

Assess all six domains: physical, mental, cognitive, psychosocial, functional and environmental (MLN909188). Date each finding and name the assessor. If no concern was found, record that finding rather than leaving the domain blank.

Step 3: Take the inventory of resources and supports

Rule: the assessment comes with an inventory of resources and supports, and comprehensive care management includes coordinating with home- and community-based clinical service providers (MLN909188). Do: ask the patient and the caregiver directly, not only the chart, and carry every gap they name into the interventions row.

Step 4: Fill the typical elements

CMS calls the elements typical, to include as medically appropriate (CMS CCM FAQ). The comprehensive plan itself is required: 99490 specifies a plan established, implemented, revised or monitored (CY2022 final rule).

• Keep the template rows; have the practitioner mark an inapplicable row and explain why. This is a template convention, not a CMS requirement to complete every row.
• Always complete the Review row to record what happened in the month. Revise and monitor when necessary (MLN909188).

Step 5: Name every practitioner and service the plan touches

Rule: managing care transitions covers referrals, follow-up after an emergency visit or a discharge, and continuity-of-care documents shared promptly with other practitioners; communication with home- and community-based providers about psychosocial needs and functional decline goes in the medical record (MLN909188). Do: update the coordination row in the month a referral, emergency visit or discharge happens, not at the next scheduled review.

Step 6: Share the plan and give the patient a copy when necessary

Rule: the plan is made available promptly within and outside the billing practice, and patients and caregivers get a copy when necessary (MLN909188). Do: offer a new copy after any revision that changes what the patient or caregiver does, and log it in the copies row.

Step 7: Review it every month, revise it when needed

Rule: CMS expects every scope-of-service element to be routinely provided in a given service period, one calendar month, unless it is not medically indicated or necessary (CMS CCM FAQ). Do: write “no change” when nothing changed rather than leaving the month blank, and send every change to goals, interventions or medications to the practitioner before it takes effect. The time log and the rest of the month’s record are set out in CCM documentation requirements.

Adapting the CCM care plan template for principal care management

Offering CCM without adding staff

If your staff lacks the hours for enrollment, outreach and monthly documentation, a chronic care management company can take that work on while your billing practitioner keeps the plan and every clinical decision. Under the CY2026 rules, a practitioner who exercises little oversight or lacks clinical integration should not bill CCM, whoever does the work (CMS CCM FAQ).

With Companian, your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license. Each patient has one dedicated Care Advocate, the same person every time. Which team members’ time counts toward each code is set in your services agreement, within the CMS rule that only clinical staff or billing-practitioner time counts (MLN909188).

Key takeaways

• The 99490 descriptor makes a comprehensive care plan a required element of every billed month.
• Demographics, problems, medications and medication allergies sit in certified EHR technology, and that list informs the care plan.
• The care plan elements CMS lists are typical, not a strict set of requirements.
• The plan is electronic and available inside and outside the practice, with a patient copy when necessary.
• Principal care management needs a disease-specific plan, not a comprehensive one.

Questions about the CCM care plan

What are the required elements of a CCM care plan?

The plan itself is required: 99490 cannot be billed without a comprehensive care plan that is established, implemented, revised or monitored. The elements inside it, from the problem list to caregiver assessment, are typical rather than strict, so the practitioner can mark any of them not applicable and give the reason. The Review row records which of those four things happened in each billed month.

Who creates the care plan for chronic care management?

The plan is created and revised under the billing practitioner, whose oversight and reassessment CMS says cannot be delegated. Under the CY2026 rules, clinical staff can maintain the plan and inform its updates under general supervision (CMS CCM FAQ).

How often should a CCM care plan be updated?

CMS describes a plan that is created, revised and monitored, and expects every scope-of-service element each calendar month unless not medically indicated. In practice that means a dated review each month and a revision when necessary, for example after a change in the patient’s conditions, medicines or providers.

What goals should a CCM care plan include?

Include measurable treatment goals set by the practitioner for this patient, alongside the patient’s priorities. Record the measure, baseline, target date and review date in the Goals row; complete the Patient priorities row in the patient’s own words.

Does the patient have to receive a copy of the care plan?

When necessary, yes. CMS says to give patients and caregivers a copy and to make the plan available promptly within and outside the billing practice. Log each copy you give in the Copies row.

Does CMS provide a CCM care plan template?

Not as a form. MLN909188 lists the elements a comprehensive care plan may include, and the CMS Chronic Care Management Toolkit points practices to outside samples, including AHRQ’s Shared Care Plan. The rows in this template follow the MLN909188 list, for your practice to build into its own EHR.

Chronic care management (CCM) is a Medicare Part B service that physician practices bill monthly, with CPT 99490 and 99439 covering clinical staff time and a comprehensive care plan as a required element; principal care management (PCM, whose clinical staff codes are 99426 and 99427) is the single-condition service built on a disease-specific plan. Companian supports both: your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.

Sources

1. CMS, Chronic Care Management Services (MLN909188), June 2025
2. CMS, Frequently Asked Questions about Practitioner Billing for Chronic Care Management Services, August 2022
3. CY 2022 Physician Fee Schedule final rule (86 FR 64996)
4. CY 2020 Physician Fee Schedule final rule (84 FR 62568)
5. CMS, Chronic Care Management Toolkit, October 2024

Read more: CPT 99490 and 99439 explained · Principal care management codes 99426 and 99427