The CCM+TCM service is extensive, including structured recording of patient health information, an electronic care plan addressing all health issues, accessing care management services, managing care transitions, and coordinating and sharing patient information with practitioners and providers outside the practice.

CMS requires the use of certified EHR technology to satisfy some of the CCM scope of service elements. In furnishing these aspects of the CCM service, CMS requires the use of a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year (referred to as “CCM certified technology”).

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According to the Center for Medicare & Medicaid Service (CMS), CCM is recognized as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending. Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.


Examples of chronic conditions include, but are not limited to, the following:

- Alzheimer’s disease and related dementia;
- Arthritis (osteoarthritis and rheumatoid);
- Asthma;
- Atrial fibrillation;
- Autism spectrum disorders;
- Cancer;
- Chronic Obstructive Pulmonary Disease;
- Depression;
- Diabetes;
- Heart failure;
- Hypertension;
- Ischemic heart disease;
- Osteoporosis.

Physicians and the following non-physician practitioners may bill the new CCM service:

- Certified Nurse Midwives;
- Clinical Nurse Specialists;
- Nurse Practitioners;
- Physician Assistants.

Only one practitioner may be paid for the CCM service for a given calendar month.

Certification1 Certification2 Certification3
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CyberMed Health Inc. is a health information technology company founded in 2011, focused on improving people’s health outcome through the use of technology and optimizing an online medical health practice system for health providers.

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