General Eligibility Explanation
Per CMS, an eligible CCM patient has multiple — two or more — chronic conditions expected to last at least 12 months, or until the patient's death, that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. CMS notes billing practitioners may consider CPT-suggested criteria such as number of illnesses, number of medications, or repeat admissions/ED visits when identifying candidates.
Chronic Condition Concept
CMS's CCM materials list illustrative (not exhaustive) examples of qualifying chronic conditions, including Alzheimer's disease and related dementia, arthritis, asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, COPD, depression, diabetes, glaucoma, HIV/AIDS, hypertension, and substance use disorders.
Expected Duration Considerations
The chronic conditions must be expected to last at least 12 months, or until the patient's death — a short-term or fully resolved condition does not meet this criterion on its own.
Risk Considerations
Beyond the duration and count requirements, the conditions must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline — the eligibility standard is about clinical risk, not simply having multiple diagnoses on a chart.
Patient Consent
The billing practitioner must obtain the patient's written or verbal consent before billing CCM, documenting that the patient was informed of CCM's availability, potential cost-sharing, that only one practitioner can bill CCM per month, and the patient's right to stop services at any time. Consent is required once, not monthly.
Care Plan
An eligible, enrolled patient must have a patient-centered, electronic comprehensive care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental assessment — covering items such as a problem list, expected outcomes and prognosis, measurable treatment goals, symptom management, and planned interventions.
Provider Considerations
CCM services can be billed by physicians (MDs/DOs), certified nurse-midwives, clinical nurse specialists, nurse practitioners, and physician assistants. A prior initiating visit is required for a new patient, or one not seen within the past year, conducted as a comprehensive face-to-face E/M visit, annual wellness visit, or initial preventive physical exam.
Example Scenarios
Examples only, not real patients. A patient with well-controlled hypertension alone would not typically meet CCM's criteria on that basis. A patient with type 2 diabetes and congestive heart failure, both expected to persist long-term and carrying meaningful risk of decompensation, more commonly fits the pattern CMS describes — the treating provider makes the actual determination in every case.
Check Common Eligibility Criteria
Check Common CCM Eligibility Criteria
Answer a few general yes/no questions to see whether a patient's condition profile commonly aligns with Medicare's CCM eligibility criteria. No patient-identifying information is collected.
Check Common CCM Eligibility Criteria