Chronic care management (CCM) is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. The Centers for Medicare & Medicaid Services (CMS) recognizes that providing CCM services takes provider time and effort. CMS established separate payment under billing codes for the additional time and resources you spend to provide the between appointment help many of your Medicare and dually eligible (Medicare and Medicaid) patients need to stay on track with their treatments and plan for better health.

CCM codes can be billed for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation or decompensation, or functional decline. Over two thirds of people with Medicare have two or more chronic conditions, which means many of your patients can benefit from CCM services, including the help provided between visits. CCM can help you deliver coordinated care to your patients that will improve their health, increase satisfaction with their care, and make care more person-centered.

This toolkit includes information for health care professionals, professional and patient organizations, and community
groups, including tips for getting started, fact sheets on the requirements for providing CCM in practices, and
educational materials to share with patients.

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