Georgia Medicare CCM: CPT 99490 Chronic Care Management

Medicare Chronic Care Management (CCM), billed under CPT 99490, pays your Georgia primary care practice to coordinate your care between office visits. It gives every eligible beneficiary structured non-face-to-face care coordination from a designated practitioner: a comprehensive written care plan, medication management, coordination across your other providers, and 24/7 access to a care team for urgent issues. You qualify if you have two or more conditions expected to last at least twelve months (or until death) that put you at significant risk of decline. CCM carries the standard Part B deductible plus 20% coinsurance, though the Qualified Medicare Beneficiary (QMB) program covers that cost for qualifying dual-eligible Georgians.1

Before January 1, 2015, the substantial care-coordination work primary care practices did between visits, phone calls, medication reconciliation, coordination with specialists and home health, after-hours triage, was effectively uncompensated under Medicare's traditional fee-for-service payment, which paid only for face-to-face visits. The CCM benefit created a structured way to pay for that ongoing coordination. This guide explains how CCM works, whether you qualify as a Georgia beneficiary with two or more chronic conditions, what your care plan must include, what CCM costs, how to get it started with your doctor, and how it fits alongside related Medicare care-management programs.

For Georgia beneficiaries, CCM matters because the state carries a higher-than-national burden of several major chronic conditions, hypertension, diabetes, chronic kidney disease, heart failure, chronic obstructive pulmonary disease, stroke, and Alzheimer's disease and related dementias. The two-or-more-conditions threshold captures a large share of Georgia's Medicare population, especially older beneficiaries and those who entered Medicare through Social Security Disability Insurance or the end-stage renal disease pathway. Georgia's primary care infrastructure, from academic systems like Emory Healthcare, Wellstar, and Piedmont to the federally qualified health center (FQHC) network and rural health clinics, delivers CCM across the state.

Do You Qualify for CCM?

To qualify for CCM, you must have at least two chronic conditions. Those conditions must:

• Be expected to last at least twelve months, or until your death
• Place you at significant risk of death, acute exacerbation, decompensation, or functional decline

The two-or-more-conditions test is designed to identify beneficiaries whose care needs coordination across multiple diseases. Most older Medicare beneficiaries meet it. CMS does not keep a closed list of qualifying conditions; your physician documents which of your conditions qualify based on your clinical situation.

Common qualifying chronic conditions include hypertension, heart failure, coronary artery disease, atrial fibrillation, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, asthma, stroke, Alzheimer's disease and related dementias, Parkinson's disease, arthritis, osteoporosis, depression, anxiety, and cancer, among many others. The twelve-month duration requirement excludes short-term or acute problems (a bout of flu, routine post-surgical recovery); the vast majority of chronic conditions in older adults meet it easily.

CCM is available to beneficiaries enrolled in Medicare Part B, including Original Medicare beneficiaries, Medicare Advantage enrollees (subject to plan rules), and dual-eligible beneficiaries enrolled in both Medicare and Medicaid. For Georgia dual-eligible beneficiaries with full Medicaid through the Georgia Department of Community Health, Medicare pays as primary, and Medicaid may cover the coinsurance or deductible through the Qualified Medicare Beneficiary program or similar wraparound coverage.

How to Get CCM Started

If you think CCM would help you, here is the practical path to getting it going with your care team.

What Does CPT 99490 Chronic Care Management Cost You?

CCM is subject to standard Medicare Part B cost-sharing: the annual Part B deductible applies, and after it is met you pay 20% coinsurance of the Medicare-approved amount. CCM is not a preventive service, so it is not covered by the Affordable Care Act preventive-services cost-sharing waiver. That out-of-pocket share is a real barrier for some beneficiaries, particularly those without Medicaid or a Medicare Supplement (Medigap) policy.1

For Georgia dual-eligible beneficiaries, the Qualified Medicare Beneficiary (QMB) program covers Medicare cost-sharing, including the Part B deductible and the 20% coinsurance, for CCM. Beneficiaries in the Specified Low-Income Medicare Beneficiary (SLMB) or Qualifying Individual (QI) programs do not get help with Medicare cost-sharing through those programs; they pay the deductible and coinsurance out of pocket unless they have other coverage. For Medicare Advantage enrollees, CCM cost-sharing follows the plan's rules, which may set lower or zero copayments.1

The CPT 99490 Chronic Care Management Coding Framework

CCM is billed under a family of codes that Medicare has built out through annual updates to the Medicare Physician Fee Schedule since the benefit began on January 1, 2015. The statutory authority is Section 1861(s)(2)(B) of the Social Security Act, which authorizes Medicare payment for physician and qualified-provider services; CMS defines the CCM codes within that framework.

• CPT 99490 is the base code: at least 20 minutes of clinical staff time per calendar month, directed by a physician or other qualified health care professional, for a patient with two or more qualifying chronic conditions and a comprehensive care plan. It is billed once per calendar month.
• CPT 99439 is the non-complex add-on for each additional 20 minutes of clinical staff time beyond the base 20 minutes; it can be billed up to two times per month, supporting up to 60 minutes of non-complex CCM per month.
• CPT 99487 is the complex CCM base code, for 60 minutes of clinical staff time per month when the care requires moderate or high complexity medical decision making. CPT 99489 is its add-on for each additional 30 minutes.
• CPT 99491 captures at least 30 minutes of CCM time furnished personally by the physician (rather than by clinical staff); CPT 99437 is its add-on for each additional 30 minutes.
• HCPCS G0506 is the one-time initial comprehensive assessment and care-plan-establishment add-on, billed when the physician personally sets up your CCM care plan at the start.
• HCPCS G0511 is the bundled monthly care-management code for FQHCs and rural health clinics, where the standard CPT structure does not apply. It covers CCM (and Behavioral Health Integration) in those safety-net and rural settings.

Clinical staff can furnish the CCM time billed under CPT 99490/99439/99487/99489 under the physician's general supervision, through the Medicare "incident-to" framework at 42 CFR 410.26. The FQHC/RHC payment methodology that G0511 operates within is set at 42 CFR 405.2466.

What Your CCM Care Plan Must Include

A comprehensive care plan is a foundational requirement of CCM. It must be written and electronic (stored in your provider's health record), shared with you in a form you can understand, and shared with your other providers as appropriate. It has to address your whole clinical picture, not just one condition. The plan must include:

1. Problem list: your chronic conditions and other health problems, with status and prognosis for each.
2. Expected outcomes and prognosis: the anticipated trajectory for each condition.
3. Measurable treatment goals: specific, time-bound goals for each major condition.
4. Symptom management: current symptoms, planned interventions, and escalation steps.
5. Planned interventions: medication changes, monitoring, specialist consults, and lifestyle steps planned over the coming period.
6. Who is responsible for each intervention: primary care, specialist, care manager, you, or a family caregiver.
7. Medication management: full reconciliation, review for appropriateness, adherence support, and deprescribing where appropriate.
8. Community and social services: home health, hospice or palliative care, social work, transportation, meals, adult day health, or area agency on aging services that have been ordered or recommended.
9. Coordination with other practitioners: how the plan connects with your specialists, home health, and other providers.
10. A review-and-revision schedule: when the plan will be reviewed and updated, at least annually and sooner when your situation changes materially.

Do You Have to Consent to CCM?

Yes. Your provider must obtain your consent, verbal or written, before starting CCM. The consent discussion must disclose the nature of CCM, that only one practitioner can furnish and bill CCM for you in a calendar month, that you may revoke consent at any time, that CCM carries the standard Part B deductible and 20% coinsurance, and that other coverage (Medicaid, Medigap, or a Medicare Advantage plan) may pay that cost-sharing. If consent is verbal, the discussion is documented in your record; if written, a signed form is retained. You can stop CCM at any time, after which CCM billing must cease the following month, though your practice continues to provide your regular care.1

Your 24/7 Access and Designated Practitioner

CCM requires the practice to give you 24/7 access to a care team member for urgent clinical issues, typically through after-hours nurse triage, on-call provider coverage, or secure messaging with a response commitment. Whoever answers must have access to your clinical information (usually the health record) and be able to address an urgent issue; a generic answering service that only forwards messages does not satisfy the requirement.

CCM is also built around continuity with a designated practitioner, the named billing provider, usually your primary care physician, nurse practitioner, or physician assistant, who knows your situation and preferences. That is why only one practitioner can bill CCM for you in a given calendar month: the rule prevents duplicate billing across practices and keeps CCM anchored to a single care relationship. Your designated practitioner can change over time if you switch practices, but only one bills CCM in any month.

How CCM Works With Other Care-Management Programs

CCM is one of several Medicare care-management benefits, and they are designed to fit together. The table below shows how CCM compares with Principal Care Management, Transitional Care Management, and Behavioral Health Integration, and whether each can run in the same month as CCM.

A primary care physician can bill CCM while a specialist bills Principal Care Management (PCM) for one specific condition in the same month. Transitional Care Management (TCM) and CCM cannot both be billed in the same month, so a practice bills TCM for the post-discharge month and resumes CCM afterward. CCM and Behavioral Health Integration (BHI) can run together when you have both medical and behavioral health needs. And the Annual Wellness Visit pairs naturally with CCM: the wellness visit can establish or update your CCM care plan (supporting the one-time G0506 assessment), and CCM then operationalizes that plan month to month.

Can CCM Be Done by Phone? (Telehealth)

By design, CCM is a non-face-to-face service. The clinical staff time under CPT 99490 is typically telephone calls, secure messaging through a patient portal, medication reconciliation with your pharmacy, and coordination calls with your other providers. CCM does not require any specific telehealth technology, the coordination can happen by phone, message, or video, which makes it well suited to rural Georgia, where travel distances and workforce shortages make in-person coordination impractical. The physician-personally-furnished codes (CPT 99491/99437) can likewise be furnished by phone or video.

Who Provides CCM and Where

CCM may be furnished by physicians (including family medicine, internal medicine, and geriatric medicine), nurse practitioners, physician assistants, clinical nurse specialists, and, in FQHC and RHC settings, certified nurse-midwives. Clinical staff who furnish CCM time under physician supervision include registered nurses, licensed practical nurses, medical assistants, pharmacists, and clinical social workers. Because CCM is non-face-to-face, the "setting" is the billing provider's enrollment, primary care offices, multispecialty groups, hospital outpatient departments, FQHCs and RHCs (under G0511), and critical access hospitals, rather than a physical place you visit.

The Georgia CCM Landscape

Georgia's primary care infrastructure delivers CCM across the state:

• Academic and health-system primary care, including Emory Healthcare (metro Atlanta), Wellstar Health System (north and northwest Georgia), Piedmont Healthcare (central and north Georgia), Northside Hospital, Augusta University Health, Atrium Health Navicent (Macon), Memorial Health (Savannah), and Phoebe Putney Health System (Albany).
• The FQHC network, such as Mercy Care, Whitefoord, West End Medical, Albany Area Primary Health Care, Curtis V. Cooper Primary Health Care (Savannah), and Diversity Health Center (Macon), which deliver CCM under the HCPCS G0511 bundled code.
• Rural primary care, including rural health clinics billing G0511, critical access hospitals operating primary care clinics, and independent rural practices.

Worked Examples: Three Georgia CCM Scenarios

The following scenarios are hypothetical illustrations of how CCM works in practice for Georgia beneficiaries.

Example #1: Newly Enrolled Non-Complex CCM in Fulton County

A 68-year-old Fulton County beneficiary is enrolled in CCM by her Emory Healthcare primary care physician after her Annual Wellness Visit. She has type 2 diabetes (A1C 8.2), controlled hypertension, stage 3 chronic kidney disease, and obesity. Her physician documents the two-or-more qualifying conditions and the significant risk of complications, personally sets up the care plan (billed once under HCPCS G0506), and obtains her verbal consent. Over the month, a registered-nurse care manager spends 25 minutes on coordination: a medication-review call, scheduling an endocrinology consult, coordinating a dietitian referral, and a call with the beneficiary's daughter about managing medications at home. The 25 minutes supports CPT 99490 billing for the month.

Example #2: Complex CCM in DeKalb County

A 75-year-old DeKalb County beneficiary is enrolled in complex CCM by his Piedmont Healthcare geriatric physician. He has atrial fibrillation on a blood thinner, heart failure, stage 4 chronic kidney disease, COPD, mild cognitive impairment, and a recent fall, a picture that meets the moderate-to-high complexity threshold. His care manager spends 65 minutes over the month: reconciling medications with a pharmacist, coordinating with cardiology and nephrology, arranging a falls-prevention physical therapy referral and a home-safety evaluation, and holding a family meeting about goals of care. The 65 minutes supports complex CCM under CPT 99487.

Example #3: Rural CCM Under G0511 in Worth County

An 80-year-old Worth County beneficiary gets primary care from a rural health clinic in his community. He has COPD, heart failure with reduced ejection fraction (LVEF 35), type 2 diabetes on insulin, and osteoarthritis. Because the practice is an RHC, CCM is billed under HCPCS G0511, the bundled monthly care-management code, rather than CPT 99490. Over the month the RHC nurse care manager spends 22 minutes on medication-adherence calls, scheduling a cardiology follow-up, coordinating home-oxygen recertification, and a call with the beneficiary's son about home medications, paid at the RHC's rate structure.

The scenarios above are hypothetical and for illustration only; they are not descriptions of real patients or specific coverage determinations.

Common Issues Georgia CCM Beneficiaries Run Into

• Cost-sharing barriers. The Part B deductible and 20% coinsurance can deter beneficiaries who lack Medicaid or a Medigap policy. SLMB and QI beneficiaries do not get Medicaid help with this cost-sharing. If cost is a barrier, ask about QMB eligibility.1
• Awareness gaps. Many eligible beneficiaries have never heard of CCM. It is worth asking your practice directly whether they offer it.
• Confusion about the one-practitioner rule. If you see more than one primary care provider, only one can bill CCM in a month; make sure everyone knows who your designated CCM practitioner is.
• Rural access and workforce constraints. Some rural practices struggle to staff care-manager roles, which can limit CCM availability, though G0511 is designed to support rural and safety-net delivery.
• Telehealth access. CCM suits phone and message delivery, but beneficiaries without a reliable phone or internet can face access barriers; tell your practice how they can best reach you.

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The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.