Chronic care management, run every month without adding staff hours.

What is chronic care management?

CMS defines chronic care management as managing a patient's multiple (two or more) chronic conditions that are expected to last at least 12 months, or until death, and that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. It is care that happens between office visits: checking in, reconciling medications, coordinating with specialists and community services, and keeping a care plan current.

CMS lists examples of qualifying conditions that include Alzheimer's disease and related dementia, arthritis, asthma, atrial fibrillation, cancer, cardiovascular disease, COPD, depression, diabetes, hypertension, HIV/AIDS, and substance use disorders. Behavioral health conditions count, which matters for integrated primary care and psychiatry practices.

What Medicare requires before you bill

• An initiating visit for new patients or patients not seen in the past year: a comprehensive E/M visit (levels 2 to 5), an annual wellness visit, or an initial preventive physical exam.
• Consent, written or verbal, documented in the record. The patient is told that CCM is available, that cost sharing may apply, that only one practitioner can bill CCM in a month, and that they can stop at any time. Consent is collected once unless the patient changes CCM practitioner.
• A comprehensive care plan kept electronically, based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment, with a copy given to the patient.
• Certified EHR technology for the patient's demographics, problems, medications, and allergies.
• 24/7 access to a practitioner or clinical staff for urgent needs, and continuity with a designated member of the care team.

CCM can be billed by physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. Clinical staff time is furnished under general supervision, so the billing practitioner does not need to be physically present.

CCM codes and 2026 Medicare rates

The CCM codes are time based and billed once per calendar month. The amounts below are CY 2026 national allowed amounts in a non-facility setting. Medicare pays 80% and the patient owes 20% after the Part B deductible.

Complex CCM also requires moderate or high complexity medical decision making. For a single high-risk condition, principal care management (codes 99424 to 99427) applies instead. The 2026 CCM billing guide covers the full code set, what cannot be billed in the same month, and the documentation an auditor looks for.

Why most eligible practices never bill CCM

The revenue is real, but so is the work. Every enrolled patient needs a monthly touchpoint, a reviewed care plan, a record of who did what and for how long, and a path to a clinician when something changes. For a practice with a few hundred eligible patients, that is a full-time coordinator before a single claim goes out.

The usual answers each have a catch. Hiring a care coordinator is slow and expensive. Outsourcing to an offshore call center is not allowed: CMS does not pay for CCM furnished by people located outside the United States. And handing CCM entirely to a third party with little oversight from the billing practitioner is exactly what CMS says should not be billed.

How a Vybz AI care team runs CCM with your staff

Vybz gives a practice an AI care team led by Luna, our AI practice manager, that works inside the EHR, inbox, and phone line you already use. It does the repetitive work around CCM so your clinical staff spend their time on the conversations and decisions that are billable. Our team sets up the workflow with you, so it matches how your practice already runs CCM.

What the AI care team can take on

• Finding patients who likely qualify, from the problem lists already in your EHR, for a clinician to confirm.
• Explaining CCM to patients and recording their consent answers for your staff to verify and sign off.
• Between-visit check-ins by text, with answers summarized in the record and anything concerning routed to a person the same day.
• Answering patient messages at any hour and sending urgent needs straight to your on-call clinician.
• Preparing each month's list of who still needs a touchpoint, and the notes your staff need before they call.

What stays with your clinical staff

• The clinical conversations and care plan decisions, which are the time that counts toward 99490 and 99439.
• Confirming eligibility and consent, and the time logs that go with each claim.
• Every clinical judgment. Luna escalates; she does not diagnose or change treatment.

CCM or APCM?

Since January 2025, practices that are responsible for a patient's primary care can bill advanced primary care management (APCM) instead: three monthly codes with no time requirement. The same practitioner cannot bill CCM and APCM for a patient in the same month, so most primary care practices will choose one model per patient. Our APCM guide compares the two and explains the new 2026 behavioral health add-on codes.