Updated for 2026. A common question for practices starting Chronic Care Management is: Who can actually provide CCM services?
Medicare allows qualifying CCM activities to be performed by both billing practitioners and clinical staff, but the rules differ depending on the CPT code, who performs the work, state scope-of-practice requirements, supervision, and how the service is billed.
This guide explains who may provide CCM, who can bill Medicare, how general supervision works, and when nurses, medical assistants, and outsourced care-management teams may participate.
Who Can Bill Medicare for CCM?
CMS identifies the following practitioners as eligible to bill Chronic Care Management services when all applicable requirements are met:
- Physicians, including MDs and DOs
- Nurse Practitioners (NPs)
- Physician Assistants (PAs)
- Clinical Nurse Specialists (CNSs)
- Certified Nurse-Midwives (CNMs)
CMS notes that primary care practitioners frequently provide CCM, but eligible specialists may also provide and bill CCM when the service is within their scope of practice and they assume the appropriate care-management role.
Who Can Perform CCM Services?
CCM does not require every care-management activity to be personally performed by the billing physician or practitioner.
For several CCM codes, qualifying services may be performed by clinical staff under the direction and general supervision of the billing practitioner.
This can allow a practice to build a team-based CCM program involving appropriately qualified staff while the billing practitioner retains responsibility for oversight and patient care.
CCM Codes by Staff Type
CodeWho Performs the ServiceTime Requirement99490Clinical staff directed by physician or other qualified healthcare professionalFirst 20 minutes99439Clinical staffEach additional 20 minutes99491Physician or other qualified healthcare professional personallyFirst 30 minutes99437Physician or other qualified healthcare professional personallyEach additional 30 minutes99487Clinical staff for complex CCMFirst 60 minutes99489Clinical staff for complex CCMEach additional 30 minutes
The distinction matters because CPT 99491 and 99437 require personal time from the physician or other qualified healthcare professional. Clinical staff time cannot be substituted for the practitioner time required by those codes.
Can Nurses Provide CCM Services?
Yes, appropriately qualified nurses may perform qualifying CCM activities as clinical staff when the activities fall within their legal scope of practice and the applicable Medicare requirements are met.
Nursing activities in a CCM program may include:
- Patient follow-up
- Medication review and reconciliation
- Care-plan monitoring
- Chronic-condition education
- Symptom follow-up
- Care coordination
- Referral follow-up
- Communication with caregivers
- Transition-of-care support
- Escalating clinically significant concerns to the practitioner
The exact activities a nurse may perform depend on professional licensure, state law, employer policy, and the requirements of the CCM service being reported.
Can Medical Assistants Provide CCM Services?
Potentially, yes — but not automatically. Medicare's CCM rules focus on whether the individual qualifies as clinical staff for the service and whether the activities are permitted under applicable state law, regulation, licensure rules, and facility policy.
A medical assistant should therefore not be assumed to qualify for every CCM activity simply because they work in a medical practice.
Before including medical-assistant time in CCM billing, a practice should confirm:
- The activity is within the individual's permitted scope
- The individual meets the applicable definition of clinical staff
- The activity is part of the patient's CCM service
- The required supervision is present
- The service is properly documented
- State-specific rules allow the activity
Example
A medical assistant working within applicable state and practice requirements contacts a CCM patient to collect relevant information for the established care plan and communicates an identified concern to the supervising care team.
Whether the associated time can be counted depends on whether the employee qualifies as clinical staff and whether the specific work satisfies Medicare, CPT, state-law, and practice requirements.
What Does General Supervision Mean for CCM?
CMS assigns CCM codes describing clinical-staff activities, including CPT 99490, 99439, 99487, and 99489, to general supervision.
General supervision means the billing practitioner provides overall direction and control but does not need to be physically present while the qualifying CCM service is performed.
This is particularly important because CCM is primarily a non-face-to-face service and many care-management activities may occur by telephone or other permitted communication methods.
Does General Supervision Mean the Practitioner Can Be Completely Uninvolved?
No. CMS specifically states that CCM cannot be completely delegated to clinical staff.
The billing practitioner remains responsible for an ongoing level of involvement that may include:
- Oversight
- Management
- Collaboration
- Reassessment
- Clinical decision-making when needed
- Overall direction of the CCM service
For complex CCM, moderate- to high-complexity medical decision-making by the billing practitioner is also part of the service and cannot simply be delegated to another individual.
Can Clinical Staff Work Remotely?
Because CCM clinical-staff services are generally subject to general supervision rather than physical-presence requirements, qualifying staff activities may be performed without the billing practitioner being physically present with the staff member.
However, practices must still satisfy Medicare's incident-to requirements, applicable state law, privacy and security requirements, employment or contractual arrangements, and appropriate clinical oversight.
Can an Outsourced CCM Company Provide the Clinical Staff?
CMS allows the clinical-staff portion of CCM to be performed by staff external to the billing practice, including arrangements with a case-management company, when applicable Medicare requirements are satisfied.
CMS's current CCM guidance states that clinical staff may be employees or individuals working under contract with the billing practitioner.
However, outsourcing does not eliminate the billing practitioner's responsibility.
CMS has cautioned that CCM may not be appropriately furnished when there is little practitioner oversight or insufficient clinical integration between the outside CCM company and the billing practice.
What Should an Outsourced CCM Relationship Include?
Practices using an external care-management team should consider establishing workflows for:
- Access to appropriate patient information
- Integration with the patient's comprehensive care plan
- Clear escalation procedures
- Timely communication with the billing practitioner
- Medication and clinical updates
- Care-transition information
- Accurate activity and time documentation
- Practitioner review and oversight
- HIPAA and security requirements
- Quality assurance and audit processes
Can CCM Staff Be Located Outside the United States?
CMS's CCM FAQ states that Medicare CCM services cannot be billed when the services are furnished by individuals located outside the United States because Medicare generally prohibits payment for non-emergency services furnished outside the United States.
This is an important consideration for practices evaluating offshore care-management vendors.
Who Can Personally Provide CPT 99491?
CPT 99491 is different from clinical-staff CCM.
It represents qualifying CCM services performed personally by the physician or other qualified healthcare professional for the required amount of time.
CMS states that CPT 99491 cannot be furnished incident to the billing practitioner's services by clinical staff.
If a practice intends to bill CPT 99491, clinical-staff time cannot substitute for the required practitioner time.
Can Practitioner Time Count Toward CPT 99490?
CMS states that CPT 99490, 99439, 99487, and 99489 can include qualifying time spent directly by the billing practitioner as well as clinical staff time.
However, practitioner time counted toward those services cannot also be counted toward CPT 99491 for the same work.
This makes accurate staff-level time tracking important.
Who Is Responsible for the Patient's CCM Program?
Although multiple members of a care team may participate in providing CCM, only one physician or other qualified healthcare professional can generally bill CCM for the patient during a calendar month.
The billing practitioner should maintain sufficient involvement to coordinate the service and remain responsible for the overall care-management relationship.
What Can Clinical Staff Do During CCM?
CMS identifies several care-management activities that clinical staff may support within their permitted scope, including:
- Collecting structured patient information
- Maintaining and informing care-plan updates
- Managing aspects of chronic care
- Supporting access to care
- Documenting CCM activities
- Coordinating with the care team
- Supporting implementation of the comprehensive care plan
The exact task assignment should always be based on the staff member's training, legal scope, organizational policy, and the patient's clinical needs.
Example CCM Team Structure
Team MemberPotential RolePhysician / NP / PA / CNS / CNMBilling practitioner, overall oversight, clinical decisions and reassessmentRegistered NurseCare management, clinical follow-up, medication review and care coordination within scopeLicensed Practical/Vocational NursePermitted care-management activities within applicable scope and supervision rulesMedical AssistantPermitted clinical-staff activities when allowed by state law and practice policyExternal CCM Clinical StaffContracted care-management activities when incident-to and clinical-integration requirements are met
CCM Staffing Compliance Checklist
- Identify the Medicare-enrolled billing practitioner.
- Confirm the practitioner is eligible to bill CCM.
- Determine which staff qualify as clinical staff.
- Review state scope-of-practice requirements.
- Define which CCM activities each staff role may perform.
- Ensure general supervision requirements are satisfied.
- Maintain active practitioner involvement.
- Document staff identity and qualifying activity.
- Track time accurately by staff member.
- Do not count the same practitioner time under multiple CCM codes.
- Review external CCM vendor contracts and clinical integration.
- Verify that Medicare-billed CCM services are not being furnished from outside the United States.
- Review current CMS, CPT, MAC, and state requirements.
How ChronicSync Can Help
As a CCM program grows, multiple staff members may communicate with patients, coordinate care, manage care-plan activities, and document work throughout the month.
ChronicSync helps practices organize care-management workflows, maintain clearer activity records, track staff interactions, and create visibility across the patient's ongoing care-management journey.
A structured workflow can help practices understand who performed each activity, what happened, and how the work fits into the patient's CCM program.
Start your ChronicSync Free Pilot to explore a more organized approach to Chronic Care Management.
Frequently Asked Questions
Can nurses provide Chronic Care Management?
Yes. Appropriately qualified nurses may perform qualifying CCM clinical-staff activities when the work is within their scope of practice and Medicare supervision and billing requirements are satisfied.
Can medical assistants perform CCM?
A medical assistant may potentially perform qualifying CCM activities if the individual meets applicable clinical-staff requirements and the activities are permitted by state law, regulation, facility policy, and Medicare rules. Practices should not assume every medical assistant or every task automatically qualifies.
Does the physician have to be in the office while staff perform CCM?
For CCM codes assigned to general supervision, CMS does not require the billing practitioner to be physically present while the clinical-staff service is performed. The practitioner must still provide overall direction and control.
Can CCM be outsourced?
Yes. CMS permits external clinical staff arrangements, including case-management companies, when the applicable incident-to, supervision, contractual, and clinical-integration requirements are met.
Can an offshore team provide Medicare CCM?
CMS states that CCM cannot be billed when the service is provided by individuals located outside the United States.
Who can bill CPT 99490?
CMS identifies physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives as practitioners who may bill CCM when the applicable requirements are met.
Who must perform CPT 99491?
CPT 99491 requires the physician or other qualified healthcare professional to personally perform the qualifying care-management services. Clinical-staff time cannot replace the practitioner time required by this code.
Sources
- CMS Medicare Learning Network: Chronic Care Management Services
- CMS: Chronic Care Management Frequently Asked Questions
- CMS: Incident To Services & Supplies
- AAFP: Chronic Care Management
This article is for educational purposes only and does not constitute legal, medical, coding, employment, reimbursement, or billing advice. Scope-of-practice laws and payer requirements vary by jurisdiction and can change. Verify current CMS, CPT, Medicare Administrative Contractor, state-law, licensure, and payer requirements before billing.