CCM · Chronic Care Management
Chronic care management, run as an extension of your practice
CareTrack's care coordinators check in with your chronic patients every month, keep them on their care plans, and document every minute in your EHR, so your practice earns CCM revenue without adding staff.
Two-thirds of Medicare beneficiaries live with two or more chronic conditions, and between office visits, most of them are managing alone. Medicare's Chronic Care Management program pays practices to close that gap, but running it in-house means dedicated staff, monthly time tracking, consent workflows, and audit-ready documentation. Most practices leave the revenue, and the care, on the table.
CareTrack runs the entire program for you. We analyze your patient panel to find CCM-eligible patients, obtain consent, build dynamic care plans with your providers, and make the monthly touchpoints ourselves: medication checks, referral coordination, appointment reminders, and the 2 AM questions. Every interaction is documented directly in your EHR under your practice's name, ready to bill.
How it works
From panel to program
- 01
Analyze
We review your patient data with you to identify the Medicare patients who benefit most from chronic care management. You decide who's included.
- 02
Enroll
Our team obtains patient consent and walks each patient through what the program does for them.
- 03
Care
Care coordinators make monthly contact, work the care plan, and stay available around the clock through 24/7 Connect.
- 04
Document & bill
Interactions and time are logged in your EHR as they happen. Your practice bills Medicare with complete supporting documentation.
Reimbursement
CCM CPT codes
The billing framework your practice uses. CareTrack tracks the time and documentation behind every code.
| Code | Description | Billing | 2026 nat’l avg* |
|---|---|---|---|
| 99490 | CCM services, first 20 minutes of clinical staff time per calendar month | Once per month | $66.13 |
| 99439 | Each additional 20 minutes of clinical staff time | Up to 2× per month | $50.44 |
| 99491 | CCM services personally provided by a physician or qualified professional, first 30 minutes | Once per month | $89.18 |
| 99437 | Each additional 30 minutes of physician or qualified professional time | Per occurrence | $63.13 |
Model these rates against your panel with the ROI calculator →
Why practices run it
- New recurring Medicare revenue with no added headcount
- Fewer avoidable hospitalizations for chronic patients
- Care plan adherence handled between visits
- Audit-ready time tracking and documentation
Common questions
CCM FAQs
Why should a practice offer a CCM program?
Three reasons: patient health, staff time, and revenue. Regular monthly contact keeps chronic patients consistent with their treatment plans; our care team absorbs the calls and follow-up tasks your staff currently handles unbilled; and the program turns that previously non-billable work into recurring Medicare reimbursement for the practice.
How does the program work when we start?
We start small and scale at your pace. First, we analyze your patient data with you to select an initial group of Medicare patients who would benefit most. Your physicians review their care plans with us, our care coordinators begin monthly outreach and document every interaction in your EHR, and your practice bills Medicare for the completed services. Then we evaluate results together and expand from there, with no obligation to grow faster than you're comfortable with.
What services are provided under CCM?
Establishing concrete treatment goals, aligning expected outcomes, medication and systems management, coordination with specialists and other physicians, and caregiver support when needed, plus 24/7 access for enrolled patients through our Connect line.
Can CCM be completely delegated to clinical staff?
No. Billing physicians are expected to remain involved in the chronic care management of their enrolled patients. CareTrack operates as clinical staff under your practice's direction: we do the outreach and documentation, your providers stay in charge of the care.
Does the patient have to provide written consent?
Consent can be written or verbal. If verbal, the health record must document the date and time it was confirmed. Our enrollment workflow captures this automatically in your EHR.
Do billing practitioners need to see CCM patients face to face?
New patients who haven't had an appointment within the last year need an initial visit (IPPE or AWV) before enrolling in CCM. That's one reason our Annual Wellness Visit program pairs so well with CCM: the AWV satisfies the requirement and identifies eligible patients at the same time.
More questions? See the full FAQ or contact us.
See CCM running on your EHR
A 20-minute walkthrough with your patient panel's numbers, not a canned deck.