Last updated: November 2026
A chronic care management (CCM) program build is the written program a practice puts in place before it bills Medicare for care management between visits: eligibility, consent, the care plan, time records and what may not be billed alongside CCM. It covers principal care management (PCM) and advanced primary care management (APCM) too. Integral Healthcare Solutions (IHS) is a consulting firm. It drafts the policy, forms and audit worksheet for your clinicians to approve, and your practice runs the program.
This is program development work, one of three IHS practice lines alongside accreditation consulting and compliance services. Not coding, billing or legal advice.
What is chronic care management, and what does CMS require?
Medicare pays for CCM under the Physician Fee Schedule, and CMS sets the conditions in the CMS MLN booklet MLN909188, Chronic Care Management Services (June 2025 edition, page opened November 3, 2026). The CMS Care Management page (opened November 3, 2026) links to the same file and lists no later edition. CMS says “Chronic care management (CCM) is managing a patient’s multiple (2 or more) chronic conditions expected to last at least 12 months, or until their death.” (p. 3). Page 5 words eligibility as 2 or more such conditions “or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.” Clinicians should check eligibility policy against current CMS text.
What has to happen before the first CCM service?
The booklet says “Before CCM services can start, we require an initiating visit for new patients or patients who you haven’t seen within the previous 1 year.” (p. 5). CMS says to conduct the initiating visit during a comprehensive face-to-face evaluation and management, annual wellness or initial preventive physical exam visit, and that CCM must be discussed at it to count. Consent follows: “Get the patient’s written or verbal consent for CCM services before you bill for them.” (p. 6). You inform the patient of the availability of CCM, their possible cost-sharing responsibilities, that only 1 practitioner can provide and bill CCM in a calendar month, and their right to stop at any time, effective at the end of the calendar month, and document that you explained these points and whether the patient accepted or declined. Consent is needed only once unless the patient switches CCM practitioner.
What does the care plan have to be?
CMS describes a duty to create, revise and monitor (per code descriptors) a patient-centered, electronic comprehensive care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment and an inventory of resources and supports (p. 6). The plan is made available promptly within and outside the billing practice, and when necessary patients and caregivers get a copy. The booklet also lists 24-hour-a-day, 7-day-a-week access to physicians, other qualified practitioners or clinical staff so patients can discuss urgent needs (p. 7).
Who may bill, and who may furnish the service?
Physicians, certified nurse-midwives, clinical nurse specialists, nurse practitioners and physician assistants may bill CCM (p. 4). Clinical staff can provide CCM services the billing practitioner does not personally provide, on an “incident to” basis under that practitioner’s direction, subject to applicable state law, licensure, and scope of practice. The regulation, 42 CFR 410.26 (eCFR text current through October 30, 2026), says “Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner).” The same paragraph says only the supervising physician (or other practitioner) may bill Medicare for incident to services.
What may and may not be billed alongside CCM?
The concurrent-billing list on p. 8 gives rules a policy and checklist should carry:
- “You can’t count time toward the CCM service code for any other billed code.”
- You can bill either remote physiologic monitoring (RPM) or remote therapeutic monitoring (RTM), but not both, concurrently with any CCM or transitional care management (TCM) service.
- Non-complex and complex CCM cannot be reported for the same patient in the same calendar month.
- CCM cannot be billed during the same service period as home health care supervision, hospice care supervision or certain end-stage renal disease services.
- Complex CCM and prolonged evaluation and management services cannot be reported in the same calendar month.
- Named CCM codes can be reported for services provided during the 30-day TCM service period; the booklet lists which.
- Rural health clinics and federally qualified health centers can bill CCM and TCM for the same patient in the same period.
The booklet tells you to consult CPT instructions for other codes that cannot be billed concurrently with CCM, and says other billing restrictions may apply if you are in a CMS-sponsored model or demonstration program.
What does CMS require for advanced primary care management?
The CMS Advanced Primary Care Management Services page (opened November 3, 2026, last modified October 27, 2026) says “APCM services aren’t time based, and you can bill using an APCM HCPCS code once per month when you meet the billing requirements.” Starting January 1, 2025, you can bill for APCM if you are a physician or non-physician practitioner, you are responsible for all your patient’s primary care services, you are the focal point for all their needed health care services, and you got written or verbal consent. The page lists elements to complete “when they’re clinically appropriate for the individual patient,” and not all of them every month.
Who needs it and what triggers it
A practice builds a CCM program when it bills or plans to bill Medicare care management. The sourced triggers: APCM became billable starting January 1, 2025, and the June 2025 booklet added APCM information on p. 11; optional behavioral health integration and psychiatric collaborative care add-ons took effect January 1, 2026 and require that you meet all the requirements CMS lists and bill an APCM base code in the same month; and a practice already billing TCM, RPM or RTM has the p. 8 overlap rules to manage.
How IHS helps
Thomas G. Goddard, JD, PhD, founder of IHS and former URAC Chief Operating Officer and General Counsel, leads the work:
- Draft the program policy: eligibility, initiating visit, consent, care plan, monthly workflow and which practitioner bills.
- Draft the consent script and form, care plan template, time log design, concurrent-billing checklist and an enrollment rule stating whether each patient is in CCM, PCM or APCM.
- Draft a quarterly audit worksheet that samples charts against each requirement.
What you supply: your clinicians decide eligibility and write care plan content, your billing staff handle coding and claims, and your EHR vendor builds the fields. The real limit: a booklet is not a coverage determination, and rules can change by payment year. IHS does not code or bill and supplies no software.
What to have ready
Each item ties to the CMS MLN booklet MLN909188, Chronic Care Management Services, the CMS Advanced Primary Care Management Services page or 42 CFR 410.26.
- Evidence of a comprehensive face-to-face initiating visit, with CCM discussed at it (booklet p. 5).
- Documented consent before billing (p. 6).
- A rule for which practitioner bills each month (p. 6).
- An electronic comprehensive care plan, created, revised and monitored (p. 6).
- A description of 24/7 access (p. 7).
- A time log that keeps CCM minutes separate from minutes counted toward any other billed code (p. 8).
- A check for RPM or RTM billed in the same period as CCM or TCM (p. 8).
- A supervision record showing who directs clinical staff (42 CFR 410.26(b)(5)).
The free introductory call is the next step for turning that list into a program.
How do CCM, PCM, APCM and TCM compare?
| Topic | CCM | PCM | APCM | TCM |
|---|---|---|---|---|
| What it is | 2 or more chronic conditions expected to last at least 12 months or until death | One high-risk chronic condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death | A bundle of several care management and communication technology-based services | Coordinated care as a patient moves from an inpatient setting back to the community |
| Billing | Time per calendar month, by who performs the service | Monthly; less than 30 minutes per calendar month cannot be billed | Once per calendar month, not time based | May be covered during the 30-day period that starts when a physician discharges a Medicare patient from an inpatient stay |
| Initiating visit | New patients or patients not seen within the previous 1 year | Another initial visit required after 1 year to continue the services | New patients, with exceptions listed on the CMS APCM page | Not stated in the pages we read |
The booklet’s concurrent-billing list does not mention APCM, so the pages we read do not say how APCM and CCM interact for one patient in one month.
What does it cost?
The pages we read state no program fee. Patient cost sharing applies, and some patients have supplemental insurance (Medigap) that helps cover it (p. 5). CMS publishes the fee schedule by calendar year, and its Physician Fee Schedule page (opened November 3, 2026) lists a PFS Look-up Tool. This page states no payment amounts or code numbers.
IHS scopes each engagement after a free introductory call; this page carries no IHS figure.
What this is not
- It is not coding, billing or legal advice or a coverage determination.
- It does not guarantee payment or a clean audit; IHS supplies no software.
- IHS does not submit claims. Your practice bills.
Frequently asked questions
What is chronic care management?
CMS says “Chronic care management (CCM) is managing a patient’s multiple (2 or more) chronic conditions expected to last at least 12 months, or until their death.” (booklet p. 3).
What does CMS require before chronic care management starts?
An initiating visit, for new patients or patients you haven’t seen within the previous 1 year (booklet p. 5), and the patient’s written or verbal consent before you bill (p. 6).
What must patient consent cover for chronic care management?
Availability of CCM, possible cost-sharing responsibilities, that only 1 practitioner can provide and bill CCM in a calendar month, and the right to stop at any time (effective at the end of the calendar month), with documentation that you explained them and the patient’s answer (p. 6).
What belongs in a chronic care management care plan?
A patient-centered, electronic comprehensive care plan based on a physical, mental, cognitive, psychosocial, functional and environmental assessment and an inventory of resources and supports (p. 6).
Can we bill chronic care management with other services in the same month?
Some combinations are allowed and some are not. The booklet says “You can’t count time toward the CCM service code for any other billed code.” (p. 8), allows named CCM codes during the 30-day TCM period, and allows either RPM or RTM but not both with CCM or TCM.
Who can bill chronic care management, and who can furnish it?
Physicians, certified nurse-midwives, clinical nurse specialists, nurse practitioners and physician assistants may bill CCM (p. 4). Clinical staff can furnish services “incident to,” under the billing practitioner’s direction, subject to applicable state law, licensure and scope of practice.
How is advanced primary care management different from chronic care management?
The CMS APCM page says APCM is billed once per month and is not time based; the booklet says CCM codes are based on time per calendar month and who performs the services (p. 9).
What does IHS draft, and what do our clinicians supply?
IHS drafts the policy, consent script and form, care plan template, time log design, concurrent-billing checklist and audit worksheet. Your clinicians supply eligibility judgment and care plan content; your billing staff handle coding and claims.