Georgia Medicare Chronic Care Management CCM 2026

The Medicare Chronic Care Management benefit gives every Georgia Medicare beneficiary with two or more chronic conditions expected to last at least twelve months or until death of the beneficiary, that place the beneficiary at significant risk of death, acute exacerbation/decompensation, or functional decline, the right to receive structured non-face-to-face care coordination services from a designated primary care practitioner, including comprehensive care plan development, medication management, coordination across home and community-based providers, 24/7 access to a care team for urgent clinical issues, and continuity of care with a designated practitioner who knows the beneficiary's clinical situation and personal preferences. Chronic Care Management is billed primarily under CPT 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month) at standard Part B cost-sharing (deductible plus 20% coinsurance), with several extensions of the base code that recognize complex care management requiring moderate or high complexity medical decision making (CPT 99487/99489), physician-personally-furnished management (CPT 99491/99437), an initial comprehensive assessment add-on (HCPCS G0506), and a bundled monthly care management code for federally qualified health centers and rural health clinics (HCPCS G0511).

By Brevy Care Team · Last verified May 14, 2026

The CCM benefit represents one of the most consequential structural innovations in Medicare primary care payment of the past decade. Before January 1, 2015, the substantial non-face-to-face care coordination work that primary care practices invested in managing medically complex Medicare beneficiaries, including phone calls, medication reconciliation, coordination with specialists, coordination with home health, coordination with skilled nursing facilities, coordination with community-based services, electronic communication with patients and families, after-hours coverage, and urgent triage, was effectively uncompensated under Medicare's traditional fee-for-service payment framework that paid only for face-to-face evaluation and management encounters. The CCM framework established a structured framework for billing care coordination time delivered between in-person visits.

For Georgia Medicare beneficiaries, the CCM benefit operates within a state landscape characterized by substantial chronic disease burden. Georgia has higher-than-national prevalence of several major chronic conditions including hypertension, diabetes mellitus, chronic kidney disease, heart failure, chronic obstructive pulmonary disease, stroke, and Alzheimer's disease and related dementias. The CCM eligibility threshold of two or more chronic conditions captures a large share of Georgia's Medicare beneficiary population, particularly older beneficiaries and those entering Medicare through Social Security Disability Insurance or end-stage renal disease pathways. Georgia primary care delivery infrastructure, including major academic medical centers (Emory Healthcare, Wellstar Health System, Piedmont Healthcare, Northside Hospital, Augusta University Health, Atrium Health Navicent, Memorial Health, Phoebe Putney Health System), community primary care across the state, the federally qualified health center network, and the rural primary care infrastructure including critical access hospitals and rural health clinics, provides CCM delivery. The FQHC and RHC bundled care management code HCPCS G0511 supports CCM delivery in safety-net and rural settings where the more granular CPT coding may not be practical.

The CCM framework operates as a structurally distinct benefit from the Medicare Annual Wellness Visit (AWV) under Section 1861(hhh), the Initial Preventive Physical Examination (IPPE) under Section 1861(ww), and the Section 1861(ddd) preventive services framework. The AWV and IPPE are episodic preventive encounters that produce a written prevention plan and coordinate downstream preventive services. The CCM benefit is a continuous, longitudinal care coordination service that operates monthly, billed under separate CPT codes, with separate documentation requirements and a separate clinical structure. The CCM benefit complements the AWV: the AWV's Personalized Prevention Plan Service can establish or update a CCM-compatible care plan, and the CCM benefit operationalizes that plan through monthly care coordination. The Section 1861(ddd) preventive services framework (behavioral counseling and screening services) can be coordinated through the CCM care plan with the CCM care manager facilitating downstream preventive services referrals.

This guide explains how the Medicare CCM benefit works statutorily and clinically, what eligibility looks like for a Georgia Medicare beneficiary with two or more chronic conditions, what the required comprehensive care plan must include, how the CPT 99490/99439/99487/99489/99491/99437 coding framework operates, how the HCPCS G0506 initial comprehensive assessment add-on works for new CCM beneficiaries, how the HCPCS G0511 bundled FQHC/RHC care management code functions in safety-net and rural settings, how the patient consent requirement operates, how the 24/7 care team access requirement functions, how the continuity-of-care requirement structures the designated practitioner relationship, how CCM coordinates with Principal Care Management (PCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), and the Annual Wellness Visit, what telehealth CCM delivery looks like, and what the Georgia CCM delivery landscape provides.

The Federal Framework Underlying the Medicare CCM Benefit

CPT 99490: Effective January 1, 2015 Under the Medicare Physician Fee Schedule

The Medicare CCM benefit was established through CPT 99490 effective January 1, 2015 under the Medicare Physician Fee Schedule. CMS established CPT 99490 to pay for the substantial non-face-to-face care coordination work that primary care practices invested in managing medically complex Medicare beneficiaries, work that had been effectively uncompensated under Medicare's traditional fee-for-service payment framework.

The CY 2015 MPFS final rule recognized that primary care practices were absorbing significant clinical and administrative costs to coordinate care for chronic disease patients, and that this work was both essential to high-quality chronic disease management and not paid for by Medicare. The CY 2015 final rule established CPT 99490 with the foundational structural requirements that continue to define the CCM benefit:

• At least 20 minutes of clinical staff time per calendar month directed by a physician or qualified provider
• Two or more chronic conditions expected to last at least 12 months or until death
• Chronic conditions placing the beneficiary at significant risk of death, acute exacerbation/decompensation, or functional decline
• Comprehensive care plan
• Patient consent
• 24/7 care team access
• Continuity of care with designated practitioner
• Electronic health record care plan
• Coordination with other providers including home and community-based services

The CY 2017 MPFS final rule expanded the CCM framework by adding the complex CCM codes CPT 99487 and CPT 99489, and the initial comprehensive assessment add-on HCPCS G0506. The CY 2017 final rule also clarified documentation requirements and simplified some implementation aspects to support CCM adoption among primary care practices.

The CY 2018 MPFS final rule established the FQHC/RHC bundled care management code HCPCS G0511 to support CCM delivery in those safety-net and rural settings where the more granular CPT coding may not be practical.

The CY 2021 MPFS final rule added CPT 99439 as a non-complex CCM add-on code for each additional 20 minutes of clinical staff time beyond the base 20 minutes captured by CPT 99490. CPT 99439 can be billed up to two times per calendar month per beneficiary, supporting a maximum of 60 minutes of non-complex CCM time per calendar month.

The CY 2022 MPFS final rule added CPT 99437 as a physician-personally-furnished CCM add-on code for each additional 30 minutes of physician-personally-furnished time beyond the base 30 minutes captured by CPT 99491.

42 CFR 410.26: Incident-To Framework Supporting CCM

42 CFR 410.26 establishes the Medicare incident-to framework that permits services furnished by clinical staff (medical assistants, registered nurses, licensed practical nurses, social workers, pharmacists, and others) to be billed under the supervising physician's NPI when furnished under appropriate physician supervision. The incident-to framework is one of the most consequential applications of Medicare payment rules in modern primary care, and CCM is one of the most prominent uses of the incident-to framework.

The CCM application of incident-to allows a clinical staff member (typically an RN or LPN care manager, but potentially also a pharmacist, social worker, or other qualified clinical staff) to furnish the non-face-to-face care coordination services that constitute CCM under physician general supervision, with the services billed under CPT 99490/99439/99487/99489 (i.e., the clinical staff time codes, as distinct from CPT 99491/99437 which require physician-personally-furnished time).

The incident-to framework operates through several specific requirements:

• The services must be furnished in accordance with a service-specific plan of care established by the supervising physician.
• The services must be furnished by clinical staff under the general supervision of the physician (general supervision means the physician must be available for consultation but does not need to be physically present in the office).
• The services must be furnished as part of the physician's regular course of practice.
• The supervising physician must be a participating Medicare provider with the relationship to the beneficiary.

Section 1861(s)(2)(B) Physician Services Authority

The underlying statutory authority for CCM payment is Section 1861(s)(2)(B) of the Social Security Act, which authorizes Medicare payment for services furnished by physicians and certain qualified providers. CMS uses its rulemaking authority under the Medicare Physician Fee Schedule to establish CCM-specific codes within the Section 1861(s)(2)(B) framework.

CCM and the Annual Update of the Medicare Physician Fee Schedule

The CCM coding framework continues to evolve through annual updates to the Medicare Physician Fee Schedule. Each year's MPFS final rule may add new CCM codes, modify existing CCM code definitions, update CCM payment rates, refine documentation requirements, or clarify CCM-related policy. Primary care practices delivering CCM in Georgia must monitor each year's MPFS final rule to stay current with CCM policy.

The CCM Eligibility Criteria

Two-or-More Chronic Conditions Requirement

The foundational CCM eligibility criterion is that the beneficiary must have at least two chronic conditions. The chronic conditions must:

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

The "two-or-more chronic conditions" framework is designed to identify Medicare beneficiaries whose clinical situation requires ongoing care coordination across multiple disease processes. The vast majority of older Medicare beneficiaries meet this criterion. CMS does not maintain a closed list of chronic conditions that qualify; the determination is made based on the beneficiary's clinical situation as documented by the supervising physician.

Common chronic conditions that frequently appear in CCM-eligible Georgia beneficiaries include:

• Hypertension
• Heart failure
• Coronary artery disease
• Atrial fibrillation
• Chronic kidney disease
• End-stage renal disease
• Diabetes mellitus type 1 or type 2
• Diabetic neuropathy
• Diabetic retinopathy
• Chronic obstructive pulmonary disease
• Asthma
• Sleep apnea
• Stroke
• Transient ischemic attacks
• Alzheimer's disease and related dementias
• Mild cognitive impairment
• Parkinson's disease
• Multiple sclerosis
• Rheumatoid arthritis
• Osteoarthritis
• Osteoporosis
• Major depressive disorder
• Generalized anxiety disorder
• Bipolar disorder
• Schizophrenia and related disorders
• Substance use disorders
• Cancer (active or in remission)
• HIV/AIDS
• Hepatitis B
• Hepatitis C
• Liver cirrhosis

The "significant risk" component requires the supervising physician to document why the chronic conditions place the beneficiary at risk of adverse outcomes. The risk documentation should connect the specific chronic conditions to the specific risk of death, acute exacerbation, decompensation, or functional decline.

Twelve-Month Duration Requirement

The chronic conditions must be expected to last at least twelve months. This duration requirement excludes acute conditions (such as influenza or community-acquired pneumonia without complications), short-term conditions (such as routine post-operative recovery), and conditions that are reasonably expected to resolve within twelve months. The vast majority of chronic medical conditions in older adults easily meet this duration requirement.

Eligible Beneficiary Population

CCM is available to Medicare beneficiaries enrolled in Medicare Part B with at least two qualifying chronic conditions. CCM is available to:

• Original Medicare beneficiaries (Part A and Part B fee-for-service)
• Medicare Advantage enrollees (subject to plan-specific rules)
• Dual-eligible beneficiaries enrolled in both Medicare and Medicaid
• Medicare Savings Program beneficiaries

For Georgia dual-eligible beneficiaries with full Medicaid coverage through DCH, the Medicare CCM benefit operates as the primary payer with Medicaid potentially covering coinsurance or deductible obligations through the Qualified Medicare Beneficiary program or similar Medicaid wraparound coverage.

The CCM Coding Framework

CPT 99490: Non-Complex CCM Base Code

CPT 99490 is the foundational CCM code. The code definition specifies:

• Chronic care management services
• At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional
• Per calendar month
• For a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
• Comprehensive care plan established, implemented, revised, or monitored

CPT 99490 is billed once per calendar month per beneficiary, when at least 20 minutes of clinical staff time has been spent on CCM activities during the calendar month.

CPT 99439: Non-Complex CCM Add-On

CPT 99439 is the add-on code for additional clinical staff time beyond the initial 20 minutes captured by CPT 99490. CPT 99439 is defined as "Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month." CPT 99439 can be billed up to two times per calendar month per beneficiary, supporting a maximum of 60 minutes of non-complex CCM clinical staff time per month (20 minutes CPT 99490 + 20 minutes first 99439 unit + 20 minutes second 99439 unit).

CPT 99487: Complex CCM Base Code

CPT 99487 is the complex CCM base code, used when the CCM encounter requires moderate or high complexity medical decision making. CPT 99487 is defined as "Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; establishment or substantial revision of a comprehensive care plan; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month."

CPT 99487 captures clinical staff time at the 60-minute threshold (vs. the 20-minute threshold for non-complex CCM). The MDM complexity requirement is the key clinical distinction; complex CCM is appropriate for beneficiaries whose chronic disease management requires sophisticated clinical decision making about multiple interacting conditions, complex medication regimens, multiple provider coordination, and active management of decompensation risk.

CPT 99489: Complex CCM Add-On

CPT 99489 is the complex CCM add-on for each additional 30 minutes of clinical staff time beyond the initial 60 minutes captured by CPT 99487. CPT 99489 has no specified maximum number of units per calendar month.

CPT 99491: Physician-Personally-Furnished CCM

CPT 99491 is the physician-personally-furnished CCM code, used when the CCM time is furnished personally by the physician or other qualified health care professional rather than by clinical staff under physician supervision. CPT 99491 is defined as "Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month."

The CPT 99491 framework recognizes that some CCM time is appropriately furnished by the physician personally, for example, complex medication management decisions, coordination with specialty consultants requiring physician-to-physician communication, or sensitive care planning discussions with the beneficiary and family. CPT 99491 is appropriate when the physician's personal time on CCM activities reaches the 30-minute threshold.

CPT 99437: Physician-Personally-Furnished CCM Add-On

CPT 99437 is the physician-personally-furnished CCM add-on for each additional 30 minutes of physician-personally-furnished time beyond the initial 30 minutes captured by CPT 99491.

HCPCS G0506: Comprehensive Assessment and Care Plan Establishment

HCPCS G0506 is the initial comprehensive assessment and care plan establishment add-on code. G0506 is defined as "Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (billed separately from monthly care management services) (Add-on code, list separately in addition to primary service)."

G0506 is billed once per beneficiary at CCM initiation when the physician personally conducts a comprehensive assessment and establishes the CCM care plan. G0506 is billed in addition to either CPT 99490 (or the complex CCM equivalent CPT 99487) for the calendar month in which CCM is initiated.

HCPCS G0511: FQHC and RHC Bundled Care Management

HCPCS G0511 is the bundled monthly care management code for federally qualified health centers and rural health clinics. G0511 is defined as "Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, nurse practitioner, physician assistant, or certified nurse-midwife), per calendar month."

G0511 supports CCM delivery in FQHC and RHC settings where the standard CPT 99490 coding framework is not directly applicable. The FQHC payment methodology under 42 CFR 405.2466 and the RHC payment methodology operate through facility-based all-inclusive or per-visit rates that do not directly use individual CPT codes; G0511 provides a CCM-equivalent bundled monthly care management code that operates within the FQHC and RHC payment frameworks.

G0511 also covers Behavioral Health Integration (BHI) services in FQHC and RHC settings, bundling CCM and BHI into a single monthly care management code for safety-net and rural settings.

The Comprehensive Care Plan Requirement

A foundational structural requirement of CCM is the comprehensive care plan. The care plan must be written, must be electronic (stored in the EHR), must be shared with the beneficiary, must be shared with other providers as appropriate, and must address the beneficiary's full clinical situation rather than focusing narrowly on a single condition.

Required Care Plan Components

The comprehensive care plan must include:

1. Problem list: comprehensive list of the beneficiary's chronic conditions and other health problems, with clinical status and prognosis for each.
2. Expected outcomes and prognosis: anticipated trajectory for each condition including expected functional decline, expected disease progression, and expected mortality timeline where applicable.
3. Measurable treatment goals: specific, measurable, time-bound goals for each major condition.
4. Symptom management: current symptoms requiring management, planned symptom management interventions, and escalation protocols for symptom worsening.
5. Planned interventions: clinical interventions planned over the next period including medication changes, lab and imaging monitoring, specialist consultations, procedures, and lifestyle interventions.
6. Identification of individuals responsible for each intervention: clear designation of who (primary care, specialist, care manager, patient, family caregiver) is responsible for each planned intervention.
7. Medication management: complete medication reconciliation, medication review for appropriateness, adherence support, deprescribing where appropriate.
8. Community and social services ordered: community-based services (home health, hospice, palliative care, social work, transportation, meal delivery, adult day health, area agency on aging services) that have been ordered or are recommended.
9. Coordination with other practitioners: coordination plans with specialists, surgical consultants, home health, skilled nursing facilities, and other providers.
10. Periodic review and revision schedule: schedule for periodic care plan review and updating.

Care Plan Format and Accessibility

The care plan must be electronic (stored in the EHR). The care plan must be shared with the beneficiary in a format the beneficiary can understand. The care plan must be accessible to other providers caring for the beneficiary, typically through electronic exchange, secure messaging, or copies provided directly to specific providers.

Care Plan Review and Revision

The care plan must be reviewed and revised periodically, typically at least annually, and more frequently when the beneficiary's clinical situation changes substantially (new diagnosis, hospitalization, significant decompensation, transition of care setting).

The Patient Consent Requirement

CCM requires patient consent before furnishing services. The consent may be either written or verbal, with specific documentation requirements.

Required Disclosure Elements

The patient consent must disclose:

• The nature of CCM services
• That only one practitioner can furnish and bill CCM for the beneficiary in a given calendar month
• That the beneficiary may revoke CCM consent at any time
• That CCM is subject to standard Part B cost-sharing (deductible plus 20% coinsurance)
• That the beneficiary may have other coverage that pays the cost-sharing (Medicaid, Medicare Supplement, Medicare Advantage cost-sharing provisions)

Documentation Requirements

If consent is verbal, the consent discussion must be documented in the medical record with the date, time, and substance of the discussion. If consent is written, a signed consent form is retained in the medical record.

Revocation

The beneficiary may revoke CCM consent at any time. Upon revocation, CCM billing must cease for the calendar month following revocation. The practice may continue to provide care to the beneficiary; only the CCM-specific billing is affected.

The 24/7 Care Team Access Requirement

CCM requires the practice to provide 24/7 access to a care team member for urgent clinical issues. This requirement reflects the recognition that beneficiaries with significant chronic disease burden require accessible clinical support outside normal business hours.

The 24/7 access requirement typically operates through:

• After-hours nurse triage operated by the practice or contracted with a triage service
• On-call provider coverage with phone access
• Secure messaging with after-hours response commitments

The 24/7 access must connect the beneficiary with a care team member who has access to the beneficiary's clinical information (typically the EHR) and can address urgent clinical issues. A generic after-hours answering service that simply forwards messages does not satisfy the 24/7 access requirement.

The Continuity-of-Care Requirement

CCM requires continuity of care with a designated practitioner. The designated practitioner is the named billing provider, typically the beneficiary's primary care physician, primary care nurse practitioner, or primary care physician assistant.

The continuity-of-care requirement structures the CCM relationship as one between the beneficiary and a specific named practitioner who knows the beneficiary's clinical situation and personal preferences. The continuity requirement is distinguishable from a generic care management service furnished by a rotating care manager pool; CCM is structured around a designated practitioner relationship.

The One-Practitioner-Per-Beneficiary-Per-Calendar-Month Rule

Only one practitioner can bill CCM for a beneficiary in a given calendar month. This rule prevents duplicate billing across multiple primary care providers and structures CCM as a designated-practitioner relationship.

The one-practitioner rule operates at the calendar month level rather than the encounter level. A beneficiary cannot have CPT 99490 billed by two different practices for the same calendar month. The beneficiary's designated CCM practitioner may change over time, for example, the beneficiary may move from one practice to another, or may transfer care from one primary care physician to another, but only one practitioner bills CCM for any given calendar month.

The one-practitioner rule has practical implications for coordination across primary care and specialty care. A beneficiary receiving CCM from a primary care physician may also receive Principal Care Management (PCM) from a specialist for a specific chronic condition (e.g., chronic kidney disease management by a nephrologist). PCM is a separate code framework (CPT 99424/99425/99426/99427) that can coexist with CCM in the same calendar month, with the primary care physician billing CCM and the specialist billing PCM for the same beneficiary in the same month.

CCM Cost-Sharing Framework

CCM is subject to standard Medicare Part B cost-sharing:

• Part B deductible applies
• 20% coinsurance applies after deductible

CCM is NOT subject to the ACA Section 4104 preventive services cost-sharing waiver, because CCM is not classified as a preventive service. The standard Part B cost-sharing creates a financial barrier for some beneficiaries, particularly low-income beneficiaries without Medicaid or Medicare Supplement coverage.

For Georgia dual-eligible beneficiaries with full Medicaid coverage through DCH, the Qualified Medicare Beneficiary program covers Medicare cost-sharing including the Part B deductible and 20% coinsurance for CCM. For Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) program beneficiaries, Medicaid does not cover Medicare cost-sharing; these beneficiaries pay the Part B deductible and 20% coinsurance out-of-pocket unless they have other coverage.

For Georgia Medicare Advantage enrollees, CCM cost-sharing operates under the plan's specific cost-sharing rules, which may include lower copayments or zero copayments for CCM depending on the plan design.

Coordination With Principal Care Management (PCM)

Principal Care Management (PCM) is a related but distinct care management framework, established through CPT 99424/99425/99426/99427 effective January 1, 2022 under the Medicare Physician Fee Schedule. PCM differs from CCM in two key respects:

• Single-condition focus: PCM is for management of a single complex chronic condition (e.g., chronic kidney disease, heart failure, COPD, dementia) rather than the multiple-condition CCM framework.
• Specialist orientation: PCM is commonly furnished by specialists who manage a specific chronic condition (e.g., nephrologists, cardiologists, pulmonologists, neurologists), though it can also be furnished by primary care.

The PCM coding framework:

• CPT 99424: physician-personally-furnished PCM, 30 minutes
• CPT 99425: physician-personally-furnished PCM add-on, each additional 30 minutes
• CPT 99426: clinical staff PCM, 30 minutes
• CPT 99427: clinical staff PCM add-on, each additional 30 minutes

CCM and PCM can coexist for the same beneficiary in the same calendar month, with the primary care physician billing CCM and a specialist billing PCM for management of a specific chronic condition. The CCM care plan should reference the PCM relationship and coordinate with the specialist's PCM activities.

Coordination With Transitional Care Management (TCM)

Transitional Care Management (TCM) is a separate Medicare benefit that pays for care coordination during the transition from inpatient or skilled nursing facility care back to the community. TCM is billed under CPT 99495 (moderate complexity TCM) or CPT 99496 (high complexity TCM), with the TCM service covering the 30-day post-discharge period.

CCM and TCM cannot both be billed for the same beneficiary for the same month. The TCM service captures the care coordination during the 30-day post-discharge period; the CCM benefit operates for ongoing care coordination outside the TCM window. Practices typically bill TCM for the post-discharge transition month and resume CCM billing in subsequent months once the TCM window closes.

Coordination With Behavioral Health Integration (BHI)

Behavioral Health Integration (BHI) is a related but distinct care management framework for integrated primary care and behavioral health management. BHI is billed under CPT 99484 (general BHI) and the Collaborative Care Model codes CPT 99492/99493/99494.

CCM and BHI can coexist for the same beneficiary in the same calendar month when the beneficiary has both medical chronic conditions warranting CCM and behavioral health conditions warranting BHI. The CCM and BHI care plans should be coordinated, with the CCM care plan documenting the BHI activities and the BHI activities reflecting awareness of the broader CCM care plan.

In FQHC and RHC settings, the HCPCS G0511 bundled care management code covers both CCM and BHI activities; these settings cannot separately bill CPT 99490 and CPT 99484.

Coordination With the Annual Wellness Visit

CCM and the Medicare Annual Wellness Visit (AWV) under Section 1861(hhh) are complementary rather than redundant. The AWV is an annual encounter that produces a Personalized Prevention Plan Service (PPPS), a written 5-10 year preventive services schedule and care plan. The CCM benefit operationalizes the AWV care plan through monthly care coordination.

The AWV can be used to:

• Establish or update the CCM care plan
• Identify CCM eligibility (the 2+ chronic conditions documentation)
• Conduct the comprehensive assessment that supports HCPCS G0506 billing at CCM initiation
• Coordinate downstream preventive services that the CCM care manager facilitates monthly

The CCM benefit can be used to:

• Operationalize the AWV's PPPS through monthly care coordination
• Track progress on AWV-identified preventive services
• Coordinate AWV-identified specialist consultations
• Manage medication changes initiated at the AWV
• Facilitate adherence to AWV-recommended lifestyle interventions

A beneficiary can have an AWV and CCM billed for the same calendar month; they are structurally distinct services with distinct coding and documentation.

Telehealth CCM Delivery

CCM is, by design, primarily a non-face-to-face care coordination service. The clinical staff time captured by CPT 99490 typically includes telephonic communication with the beneficiary, electronic communication through patient portals, coordination phone calls with specialists and other providers, medication reconciliation through pharmacy contacts, and other non-face-to-face activities.

CCM does not require any specific telehealth technology. The clinical staff time can be furnished through telephone, secure messaging, video, or other non-face-to-face means. The CCM benefit is therefore structurally well-suited to rural Georgia delivery, where in-person care coordination would be impractical given workforce constraints and patient travel distances.

For the physician-personally-furnished CCM codes CPT 99491/99437, the physician time can also be furnished through non-face-to-face means including telephone or video. The physician-personally-furnished time is captured separately from face-to-face evaluation and management encounters.

Eligible Providers

CCM may be furnished by:

• Physicians (MD or DO), including family medicine, internal medicine, geriatric medicine, and others
• Nurse practitioners
• Physician assistants
• Clinical nurse specialists
• Certified nurse-midwives (in FQHC and RHC settings under G0511)

Clinical staff furnishing CCM under physician supervision include:

• Registered nurses
• Licensed practical nurses
• Medical assistants
• Pharmacists
• Clinical social workers
• Health educators
• Other qualified clinical staff

The supervising physician must establish the CCM care plan and provide general supervision of the clinical staff furnishing CCM time.

CCM Settings

CCM may be furnished in:

• Primary care offices
• Multispecialty group practices
• Hospital outpatient departments
• Federally qualified health centers (under HCPCS G0511)
• Rural health clinics (under HCPCS G0511)
• Critical access hospitals
• Other Medicare-enrolled provider settings

CCM is structurally a non-face-to-face service, so the "setting" refers to the billing provider's enrollment setting rather than a physical location of service. The clinical staff time can be furnished from any location with appropriate access to the EHR and the beneficiary.

The Georgia CCM Landscape

Georgia primary care infrastructure delivering CCM includes:

Major Academic Medical Centers

• Emory Healthcare: comprehensive academic primary care across metro Atlanta with established CCM programs
• Wellstar Health System: large network across north/northwest Georgia
• Piedmont Healthcare: central and north Georgia
• Northside Hospital: primarily metro Atlanta
• Augusta University Health: Augusta region academic
• Atrium Health Navicent: central Georgia (Macon)
• Memorial Health (HCA): southeast Georgia (Savannah)
• Phoebe Putney Health System: southwest Georgia (Albany)

Federally Qualified Health Center Network

Georgia FQHCs delivering CCM under HCPCS G0511 bundled care management include:

• Mercy Care (metro Atlanta)
• Whitefoord (East Atlanta)
• West End Medical (Atlanta)
• Albany Area Primary Health Care
• Curtis V. Cooper Primary Health Care (Savannah)
• Diversity Health Center (Macon)
• Four Corners Primary Care
• Other FQHCs across the state

Rural Primary Care Infrastructure

Rural Georgia CCM delivery operates through:

• Rural health clinics (RHCs) delivering CCM under HCPCS G0511
• Critical access hospitals operating primary care clinics
• Independent rural primary care practices
• Multi-county primary care networks

Worked Examples: Six Georgia CCM Scenarios

Example 1: Fulton 68 Newly Enrolled CCM, DM2 + HTN + CKD3 + Obesity

A 68-year-old Fulton County beneficiary is newly enrolled in CCM by her Emory Healthcare primary care physician following her Annual Wellness Visit. She has type 2 diabetes mellitus (A1C 8.2%), hypertension (controlled on lisinopril and amlodipine), stage 3 chronic kidney disease (eGFR 48 ml/min/1.73m²), and obesity (BMI 34.7 kg/m²). The PCP documents the 2+ chronic conditions and the significant risk of acute exacerbation and functional decline (diabetes complications, CKD progression to ESRD, cardiovascular events).

The PCP personally conducts a comprehensive assessment establishing the CCM care plan, billed under HCPCS G0506 in addition to the monthly CCM code. The care plan addresses diabetes management with A1C target 7.0-7.5%, statin therapy initiation given her CKD3 and DM2 risk profile, ACE inhibitor optimization for renoprotection, weight loss target of 7-10% to slow CKD progression, and CGM consideration for diabetes management. The PCP obtains verbal consent for CCM and documents the consent discussion.

The clinical staff care manager (registered nurse) spends 25 minutes during the calendar month on care coordination activities: monthly medication review phone call, scheduling endocrinology consultation, coordinating dietitian referral for medical nutrition therapy under Section 1861(vv), patient portal messaging about CGM workflow, and a phone call with the beneficiary's daughter regarding home medication management. The 25 minutes of clinical staff time supports CPT 99490 billing. CMS Section 1861(s)(2)(B) physician services authority underlies the payment.

Example 2: DeKalb 75 Complex CCM, AFib + HF + CKD4 + COPD + MCI + Recent Fall

A 75-year-old DeKalb County beneficiary is enrolled in complex CCM by his Piedmont Healthcare geriatric medicine physician. He has multiple chronic conditions: atrial fibrillation on apixaban, heart failure with preserved ejection fraction on furosemide and metoprolol, stage 4 chronic kidney disease (eGFR 22 ml/min/1.73m²), COPD on tiotropium and albuterol, mild cognitive impairment with MoCA 22/30, and a recent fall with hip contusion. The clinical complexity meets the moderate-to-high MDM threshold for complex CCM.

The clinical staff care manager spends 65 minutes during the calendar month on care coordination: medication reconciliation with pharmacist consultation regarding apixaban dosing in CKD4, coordination with cardiology regarding AFib management, coordination with nephrology regarding ESRD preparation and dialysis access planning, falls prevention assessment with PT referral, home safety evaluation through home health, MoCA follow-up planning with neurology, and family meeting regarding goals of care given the multiple chronic conditions and functional decline trajectory. The 65 minutes of clinical staff time supports CPT 99487 complex CCM billing.

Example 3: Cobb 72 Physician-Personally-Furnished CCM, Recent Stroke + AFib + DM2 + Depression

A 72-year-old Cobb County beneficiary is enrolled in CCM by her Wellstar primary care nurse practitioner. She had a recent ischemic stroke with residual right-sided weakness and mild dysarthria, has atrial fibrillation (the presumptive stroke etiology, now on apixaban), type 2 diabetes mellitus (A1C 7.4% on metformin and semaglutide), and major depressive disorder (PHQ-9 score 14, started on sertraline post-stroke).

The clinical staff care manager handles routine monthly care coordination including medication reconciliation, scheduling outpatient stroke rehabilitation, and coordinating with physical therapy. However, the primary care NP personally spends 35 minutes during the calendar month on more complex management: medication-by-medication review of the apixaban-sertraline pharmacology for serotonergic effects and bleeding risk; physician-to-neurologist phone call regarding secondary stroke prevention; physician-to-cardiology phone call regarding AFib management optimization; sensitive care planning discussion with the beneficiary and her husband regarding stroke recovery prognosis and advance care planning. The 35 minutes of NP-personally-furnished time supports CPT 99491 physician-personally-furnished CCM billing.

Example 4: Worth County 80 Rural FQHC CCM, COPD + HF + DM2 + Arthritis

An 80-year-old Worth County beneficiary receives primary care from a rural health clinic operating in his community. He has COPD on tiotropium and salbutamol, heart failure with reduced ejection fraction (LVEF 35%) on guideline-directed medical therapy, type 2 diabetes mellitus on metformin and insulin, and osteoarthritis with chronic back pain. The RHC primary care nurse practitioner enrolls him in CCM with verbal consent.

Because the practice is an RHC, CCM is billed under HCPCS G0511 (RHC general care management bundled monthly code) rather than the standard CPT 99490 framework. The G0511 code captures 20+ minutes of clinical staff time per calendar month for CCM activities, paid at the RHC all-inclusive rate structure. The RHC nurse care manager spends 22 minutes during the calendar month on care coordination: medication adherence phone calls, scheduling cardiology follow-up, coordinating home oxygen recertification, and a phone call with the beneficiary's son regarding home medication management. The G0511 billing operates within the RHC payment framework under 42 CFR 405.2466.

Example 5: Bibb 70 CCM + TCM Coordination, Post-Discharge Following HF Decompensation

A 70-year-old Bibb County beneficiary is hospitalized at Atrium Health Navicent for an acute heart failure decompensation. He is discharged home after a four-day stay. His primary care physician at a Macon primary care practice has previously enrolled him in CCM (billed monthly under CPT 99490 for the prior six months of CCM enrollment).

For the discharge month, the practice bills CPT 99495 (moderate complexity Transitional Care Management) rather than CPT 99490, because TCM and CCM cannot both be billed for the same beneficiary for the same month. The TCM service captures the post-discharge care coordination during the 30-day post-discharge window, including a discharge phone call within 2 business days, an in-person follow-up visit within 14 days, medication reconciliation, coordination with home health, and continued post-discharge management.

In the calendar month following the TCM window closing, the practice resumes CPT 99490 billing for ongoing monthly CCM activities. The beneficiary's continuity of CCM-billed care is preserved across the post-discharge transition with the TCM service serving as a one-month bridge during the post-discharge period.

Example 6: Hall 78 CCM + AWV Coordination With G0506 Initial Assessment

A 78-year-old Hall County beneficiary presents to her Northeast Georgia Health System primary care physician for her annual Medicare Annual Wellness Visit. She has hypertension, type 2 diabetes, osteoarthritis, hyperlipidemia, and a recent diagnosis of mild cognitive impairment after positive Mini-Cog screening at the AWV. The AWV produces a Personalized Prevention Plan Service identifying multiple preventive service needs and chronic disease management priorities.

The PCP determines that the beneficiary is appropriate for CCM enrollment given the 2+ chronic conditions and the significant risk of functional decline associated with the new MCI diagnosis. The PCP personally conducts a comprehensive assessment establishing the CCM care plan, building on the AWV's PPPS framework. The assessment is billed under HCPCS G0506 (Comprehensive assessment and care plan establishment) as an add-on to the calendar month's CCM service.

For the same calendar month, the practice bills:

• HCPCS G0438 (Initial AWV) for the AWV encounter, paid at zero cost-sharing under ACA Section 4104
• HCPCS G0506 (CCM initial comprehensive assessment) as add-on
• CPT 99490 for the calendar month's monthly CCM clinical staff time

The Part B cost-sharing applies to G0506 and CPT 99490 (deductible plus 20% coinsurance). The AWV (G0438) is at zero cost-sharing. The CCM enrollment provides ongoing monthly care coordination operationalizing the AWV's PPPS.

Best Practices for Maximizing CCM Coverage

1. Use AWV to identify CCM-eligible beneficiaries: the AWV's comprehensive HRA and history review readily identifies beneficiaries with 2+ chronic conditions warranting CCM enrollment.

2. Document the 2+ chronic conditions clearly: the supervising physician should document specifically which chronic conditions support CCM eligibility, with explicit reference to the 12-month duration and significant-risk components.

3. Use HCPCS G0506 for initial CCM enrollment: the G0506 initial comprehensive assessment add-on supports proper CCM enrollment and establishes the foundational care plan. It is separately billable in addition to the calendar month's CCM service.

4. Time-track CCM activities meticulously: CCM billing requires documentation of clinical staff time during the calendar month. Use EHR-integrated time tracking to capture care manager phone calls, electronic communications, coordination activities, and documentation time.

5. Maintain comprehensive electronic care plans: the care plan must be electronic, comprehensive, and accessible. Use EHR templates that prompt for each required care plan component.

6. Obtain and document patient consent: verbal or written consent must be documented with the required disclosure elements. Consider written consent forms for clarity.

7. Operationalize 24/7 access: establish clear after-hours coverage with care team access to clinical information. A generic answering service is not sufficient.

8. Coordinate CCM with AWV annually: use the annual AWV to review and revise the CCM care plan, identify new preventive service needs, and update the PPPS.

9. Coordinate CCM with TCM at transitions: bill TCM (not CCM) during the post-discharge month, then resume CCM in subsequent months.

10. Coordinate CCM with PCM for specialist co-management: primary care can bill CCM while specialists bill PCM for the same beneficiary in the same month.

11. Use HCPCS G0511 for FQHC/RHC CCM: safety-net and rural settings should bill G0511 rather than CPT 99490. G0511 covers both CCM and BHI in those settings.

12. Use CPT 99491/99437 for physician-personally-furnished time: when the physician's personal time on CCM activities reaches 30+ minutes per month, bill the physician-personally-furnished codes rather than the clinical staff codes.

13. Use complex CCM codes when MDM warrants: beneficiaries with high clinical complexity, multiple interacting conditions, and active decompensation risk warrant CPT 99487/99489 complex CCM rather than CPT 99490.

14. Educate beneficiaries about CCM cost-sharing: CCM is not preventive-service cost-sharing waived. Beneficiaries should understand the Part B deductible and 20% coinsurance, including any wraparound coverage (Medicaid QMB, Medicare Supplement, Medicare Advantage) that may pay the cost-sharing.

Common Issues for Georgia CCM Beneficiaries

1. Cost-sharing barriers: the standard Part B deductible and 20% coinsurance create financial barriers for some beneficiaries, particularly those without Medicaid or Medicare Supplement coverage. SLMB and QI program beneficiaries do not have Medicaid wraparound for cost-sharing.

2. Awareness gaps: many CCM-eligible beneficiaries are not aware that the CCM benefit exists. Practice marketing and education about the benefit can substantially improve uptake.

3. Consent documentation challenges: practices may struggle with the consent documentation requirements, particularly for verbal consent. Written consent forms with clear disclosure elements simplify compliance.

4. Time tracking burden: CCM billing requires meticulous time tracking. Practices without EHR-integrated time tracking may struggle to document the calendar-month time threshold.

5. 24/7 access burden: small practices may struggle to operationalize true 24/7 care team access. Shared after-hours coverage arrangements and triage service contracts can help.

6. One-practitioner-per-month confusion: beneficiaries receiving care from multiple primary care providers may experience confusion about which provider bills CCM. The designated CCM practitioner should be clearly identified and communicated.

7. CCM-TCM coordination errors: practices may bill both CCM and TCM for the same month, resulting in claim denials. The TCM service captures the post-discharge month; CCM resumes in subsequent months.

8. Complex vs. non-complex coding errors: the distinction between CPT 99490 (non-complex, 20 minutes) and CPT 99487 (complex, 60 minutes, moderate/high MDM) requires careful coding judgment.

9. CCM-BHI coordination in FQHC/RHC settings: these settings bundle CCM and BHI under G0511; they cannot separately bill the underlying CPT codes.

10. Care plan maintenance burden: the comprehensive care plan must be reviewed and updated periodically. Practices without systematic care plan maintenance workflows may struggle.

11. Telehealth limitations: although CCM is well-suited to non-face-to-face delivery, beneficiaries without smartphones, computers, or reliable phone service may face access barriers.

12. Rural workforce constraints: rural Georgia practices may struggle to staff care manager positions, limiting CCM availability.

13. Specialist-primary care coordination friction: CCM-PCM coordination requires active communication between primary care and specialists, which may not occur systematically.

14. End-of-life care plan misalignment: beneficiaries approaching end-of-life may have CCM care plans that do not reflect their goals of care preferences. Periodic care plan review should incorporate advance care planning discussions.

FAQ

Where to Get Help in Georgia

• Medicare: 1-800-MEDICARE (1-800-633-4227); general Medicare benefit questions
• Palmetto GBA Medicare Administrative Contractor: 1-866-238-9650; Georgia Medicare claims and provider questions
• DCH Medicaid Member Services: 1-866-211-0950; Georgia Medicaid questions including QMB and dual-eligible coverage
• GeorgiaCares SHIP: 1-866-552-4464; free Medicare counseling and enrollment assistance
• Medicare Rights Center: 1-800-333-4114; national Medicare advocacy organization
• Atlanta Legal Aid Society: 404-377-0701; free legal services for low-income metro Atlanta seniors
• Georgia Legal Services Program: 1-800-498-9469; free legal services for low-income Georgia seniors outside metro Atlanta
• 211 Georgia: dial 211; community resource referrals
• Eldercare Locator: 1-800-677-1116; national directory of local senior services
• Georgia Department of Public Health: 404-657-2700; state public health resources
• CDC-INFO: 1-800-232-4636; federal public health information
• Emory Healthcare: comprehensive academic primary care across metro Atlanta with established CCM programs
• Wellstar Health System: primary care across north and northwest Georgia
• Piedmont Healthcare: primary care across central and north Georgia
• Acentra Health (Medicare QIO for Georgia): 1-844-455-8708; quality of care concerns and complaints
• Social Security Administration: 1-800-772-1213; Medicare enrollment and benefit eligibility
• Georgia Composite Medical Board: 404-657-6494; physician licensing and complaints
• Georgia Pharmacy Association: 404-231-5074; pharmacy resources for medication management

This guide is informational and does not constitute legal, clinical, or coding advice. CCM coverage decisions are made by Palmetto GBA (Georgia's Medicare Administrative Contractor) and Medicare Advantage plans applying federal coding and policy framework. For coverage questions about specific CCM scenarios, beneficiaries and providers should contact 1-800-MEDICARE, the relevant MA plan, or Palmetto GBA directly. Last verified: 2026-05-14.

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