CCM and BHI Survival Guide.

Chronic Care Management and Behavioral Health Integration.
Made simple.

Let's start with the basics.

Chronic care management (CCM) and Behavioral Health Management are Medicare program that reimburses clinical teams for care services each month.

Medicare Patients

Patients must be on Medicare and have multiple chronic conditions to qualify.

Care Plans

You need to create a patient-centered care plan and update it periodically.

20 Minutes of Care

You must log at least 20 minutes of care services per month (outside of other billable services).

~$64+ Per Patient

After meeting the billing critieria, you can receive monthly reimbursements via various CCM and BHI codes.

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For more details on Medicare's CCM and BHI programs, please check out the rest of our guide below!

What is Chronic Care Management?

The Centers for Medicare and Medicaid Services (CMS) announced the CCM program in 2015 as a way to improve outcomes for the chronically ill while reducing costs.

Medicare Program

The CCM and BHI programs are officially sponsored by CMS, specifically targeting Medicare patients and their care teams.

Care Coordination Focus

CCM aims to bridge many of the gaps that exist in healthcare by encouraging care team outreach.

Monthly Reimbursements

Medicare provides new reimbursements to medical providers in order to successfully drive the program.

How does it work?

At a high level, CCM and BHI are simple. Care teams can earn incremental reimbursements for care services each month.

20 Minutes of Care Services


per patient per month

CCM: CPT 99490
BHI: CPT 99484

This is the "standard" or "non-complex" CCM and BHI model. These two codes can be billed together or separately for qualifying patients.

60 Minutes of Care Services


per patient per month

CCM: CPT 99487
BHI: CPT 99493

Also known as "complex CCM and BHI". These two codes can be used for especially intensive cases requiring close monitoring and management.

30 Minutes of Care Services


per patient per month

CCM: CPT 99489
BHI: CPT 99494

These are strictly add-on codes for CPT 99487 and CPT 99493 for time spent over 60 minutes.

Which patients qualify?

CMS estimates that roughly two-thirds of Medicare patients are eligible for CCM and BHI.

Medicare Beneficiaries

Patients must be Medicare Fee-For-Service (also known as "Original Medicare") beneficiaries for CCM and BHI. Medicare supplement plans are valid.

Multiple Chronic Conditions

Patients need to have two or more conditions that are expected to last at least 12 months and put the patient at risk for death, exacerbations, or functional decline.

How are services provided?

CCM and BHI activities can be completed throughout the month, and there are a few specific items to keep in mind.

Informed Consent

Before you can begin accumulating CCM and BHI service time, you need to explain the program, obtain your patient's informed consent, and document it in their medical record. This can be done at an AWV, IPPE, or E/M visit, or if you've seen the patient for such a visit in the last 12 months, you can get verbal consent.

Patient-Centered Care Plan

You must create, distribute, and periodically review a care plan for each patient. Care plans must be captured electronically and address the patient's physical, mental, cognitive, psychosocial, functional, and environmental needs, providing a road map for their health issues (with a focus on chronic conditions).

Care Management

Each month, your care team must help your patients manage their chronic conditions. This includes regular assessment of needs and adherence, in addition to care coordination across various settings and medical providers. Some of the most common activities include medication reconciliations, phone calls for care counseling, and patient referrals.

Care Accessibility

Patients need to have 24/7 access to care services, allowing them to connect with clinical staff within your practice to address any urgent situations. Your clinical team must also provide a means for patients to schedule routine follow-ups, promoting continuity of care.

Who can provide the services?

CCM and BHI are billed under a medical provider, but generally supervised care team members can contribute as well.

Medical Providers

The CCM and BHI processes must be overseen by a medical provider. This could be an MD, DO, APRN, NP, PA, CNS, or CNM.

Clinical Staff

Care team members acting under general supervision of the billing provider can help too. This includes CMAs, RNs, LPNs, social workers, or other providers.

What are the technology requirements?

CCM and BHI require the use of a certified Electronic Health Record (EHR), and certain elements must be at least electronically managed.

Certified EHR

You must use an EHR to help inform care plans and other care efforts, including coordination across teams. You also need to store your patients' demographics, problems, medications, and allergies in your EHR.

Electronic Care Plans

Care plans must be maintained electronically and accessible for your care team. In addition, you need to be able to share care plans electronically with external care teams.

Enhanced Communication

The patient must be allowed to communicate with the CCM and BHI provider and care team via phone and other secure, asynchronous methods (e.g., email, portal, secure messaging, etc.).

How does billing work?

CCM and BHI, whether "complex" or not, can be billed on a monthly basis.

One Provider

Only one provider can actively bill for a particular patient in any given month. However, that same provider can bill for both CCM and BHI services for eligible patients

Cost Sharing

Patients are responsible for standard Medicare cost sharing, which equates to ~20% of reimbursements (with no supplement).

Conflicting Codes

CCM and BHI cannot be billed alongside transitional care management (CPT 99495-99496), home healthcare supervision (HCPCS G0181), hospice care supervision (HCPCS G0182), or end-stage renal disease services (CPT 90951-90970).


In addition to monthly CCM codes, you can receive ~$65 with this add-on to a patient's initiating CCM visit. To bill for HCPCS G0506, the CCM provider supply extensive assessment and care planning during the initiating visit, which can be an AWV, IPPE, or E/M visit.

Let's review!

CCM and BHI are simple if you focus on the main aspects of the program.

Identify Medicare patients with multiple chronic conditions

Educate patients and obtain informed consent

Complete and distribute a patient-centered care plan

Log 20 minutes or more of care services per month

Meet the technology and billing requirements

Bill under CPT 99490 and/or CPT 99484 (or additional codes)

Is CCM right for your team?

The short answer is probably yes. If you've contemplated starting a CCM program, it's easier than you might think. There are a few things to keep in mind as you move forward.

Provider Eligibility

CCM can only be billed under a medical provider. Your practice must have an MD, DO, APRN, NP, PA, CNS, or CNM. Limited license practitioners like podiatrists or dentists don't qualify.

Patient Eligibility

You will need a modest number of Medicare patients with two or more chronic conditions (e.g., diabetes, hypertension, etc.). Even just 20 patients will yield over $10,000 annually.

Will it make a difference?

It only makes sense to pursue CCM if it helps your practice. Luckily, there is a lot of value packed into the program.


If your team is looking for a new source of revenue, look no further. CCM is an efficient way to bring in more money.

Patient Outcomes

If you want to further help your chronically ill patients stay on top of their conditions, CCM is great tool to leverage.

Patient Connectivity

CCM is well-suited for care teams that want to develop closer relationships with their patients, as the program reimburses for time spent in that pursuit.

How can you utilize your team?

It's vital to include the right staff members, but it's also important to know the type of work that they can leverage.

Shared Responsibility

Any clinical team members working under general supervision of the billing provider can contribute. Having many team members on the same page will help you forge a successful program.

Care Services

If your team is already providing care services outside of billable visits (e.g., patient calls for care counseling, referrals, etc.), you are well-positioned to leverage CCM.

Team Growth

If you are looking to build out your care team, CCM provides more than enough revenue to merit additional personnel.

Be sure to avoid common obstacles.

There are a few things that can prevent care teams from billing for CCM.

Conflicting Codes

CCM cannot be billed in the same month as transitional care management (CPT 99495-99496), home healthcare supervision (HCPCS G0181), hospice care supervision (HCPCS G0182), or end-stage renal disease services (CPT 90951-90970).

24/7 Access

Your team will need to be able to provide care services 24/7. This can often be accomplished by giving patients a means to contact a care team member after office hours.


Although it is becoming a less prevalent issue, it's worth noting that you need a certified EHR in order to pursue CCM.

What is the business opportunity?

There are several reasons to institute a CCM program, but perhaps one of the most compelling is creating a new source of recurring revenue.

~1600 patients for the average primary care provider

~40% are Medicare

~67% have 2 or more chronic conditions

~$64 is reimbursed per patient, per month

~$220,000 in potential annual revenue per provider

Note: Any care team members acting under general supervision of the provider can contribute.

What does that mean for individual care team members?

At a more granular level, it's easy to see that CCM can be fruitful with relatively little clinical overhead.

~$130+ per hour

By consistently recording CCM activities, care team members can generate more than enough revenue to offset their hourly pay.

Existing Care Services

Many of your current care services can likely be leveraged for CCM (e.g., phone calls for care counseling, referrals, etc.).

~$20,000+ per month

Full-time care team members can unlock substantial new revenue to help fuel your practice's operations.

What's the bottom line?

If you consider the wage of a medical assistant or nurse, CCM provides a large operating margin.

~425 CCM patients for the average primary care provider

~$64 is reimbursed per patient, per month

~$10 in costs per 20 minutes of care team time

~$170,000 in annual gross profit per provider

Don't forget that additional CCM codes (i.e., CPT 99487, CPT 99489, and HCPCS G0506) can further increase your potential revenue!

CCM Tips

We've seen a lot of teams try CCM, and some have certainly done better than others. Here are some helpful tips as you look to build out your CCM program.

Have a Leader

CCM runs more smoothly when you designate someone to oversee the program at your practice. Whether it's a care coordinator, midlevel, or otherwise, having a team member dedicated to the cause certainly helps keep things in-line.

Stick to a Process

Every team is unique, but all teams need to get in the habit of tracking relevant CCM services. It's not hard at all, but having a process (e.g., flagging CCM-eligible patients, scheduling periodic patient calls, etc.) can solidify your efforts.

Make It a Priority

If your team doesn't take CCM seriously, you'll likely struggle to consistently generate revenue. Additionally, your patients will be less likely to participate. Your team needs to see and promote the value of CCM in order to make it a reality.

Provide Rewards

Sometimes care teams need a little extra push to truly do their best. If you can provide recognition for hardworking team members, they'll be more likely to give CCM their all. Ultimately, this yields a more successful program for your practice.

Avoid Call Centers

There are a lot of CCM companies that offer care outsourcing, but several simply forward your patients onto random care personnel at a call center. This guts the value of the program, as patients often receive fractured, impersonal care.

Use the Right Tools

Excel files, paper documents, or other impromptu tools simply aren't sustainable mediums for CCM, as they scale poorly with patient volume. To stay organized and efficient, your practice should utilize an electronic solution.

Congrats, you've made it to the end of our CCM guide! We wish you the best of luck with your CCM program, and please let us know if we can ever lend a hand!

We're here to help.

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Your Care

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Cloud-based Tracking

Crafted for clinical workflows, our software helps you efficiently track your CCM and BHI activities.

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