CCM
At least two chronic conditions expected to last 12 months or until death, plus significant risk. CMS requires an initiating visit for new patients or patients not seen in the previous year, documented consent, and a comprehensive care plan.
Talk with us PUBLIC REFERENCE · CY2026
Medicare care-program requirements, in one defensible guide.
Use this source-reviewed reference to orient a practice before patient enrollment, staffing, or revenue projections. It covers Original Medicare rules and California payment context without treating a fee-schedule amount as guaranteed revenue.
Educational reference, not billing advice.
PrimeVital reviewed this edition against the cited CMS sources. It has not been certified by an independent healthcare attorney or certified coding professional. Before billing, confirm current CPT instructions, NCCI edits, MUEs, MAC guidance, payer policy, and the facts of the patient and service.
PROGRAM MAP
Start with the clinical use and billing structure.
This broader Medicare reference includes CHI and chronic pain management in addition to PrimeVital’s nine current program pathways. Inclusion here explains a Medicare service; it does not mean PrimeVital offers it today. A diagnosis alone does not establish that a monthly service is billable. Each program has its own eligibility, performer, consent, time, device-day, communication, supervision, and documentation requirements.
| Program | Clinical use | Billing structure |
|---|---|---|
| CCMChronic Care Management | Two or more qualifying chronic conditions | Monthly time based |
| APCMAdvanced Primary Care Management | Longitudinal primary care | Monthly, not time based |
| TCMTransitional Care Management | Thirty days after a qualifying discharge | Contact and visit deadlines |
| RPMRemote Physiologic Monitoring | Connected physiologic-data monitoring | Setup, device, and management |
| RTMRemote Therapeutic Monitoring | Therapy adherence or response | Setup, device, and management |
| BHI / CoCMBehavioral Health Integration | Integrated behavioral and medical care | Monthly team-based services |
| PCMPrincipal Care Management | One high-risk chronic condition | Monthly time based |
| PIN / CHINavigation and social-needs support | Serious illness or treatment-limiting social need | Monthly time based |
| CPMChronic Pain Management | Chronic pain care bundle | Practitioner-led monthly service |
| MTMMedication Therapy Management | Part D plan-sponsored program | Plan-specific, not a Part B PFS rate |
WHO BILLS · WHO PERFORMS · WHO OWNS THE WORK
The practitioner’s responsibility does not disappear when support is outsourced.
This is an Original Medicare physician-fee-schedule orientation, not a credential-by-code billing determination. Role titles alone are insufficient: the code, practitioner enrollment, state scope, supervision, location, and payer rules control.
CCMView billing and team boundaries
Who billsA physician or other eligible billing practitioner owns the service. The 99491/99437 practitioner-time pathway cannot be delegated.
Who can supportQualified clinical staff may furnish the staff-time pathway under general supervision. CMS expressly permits external clinical staff when incident-to rules and clinical integration are met.
Boundary to verifyThe billing practitioner retains oversight, care-plan responsibility, and required work. CMS says CCM furnished by individuals outside the U.S. is not billable.
APCMView billing and team boundaries
Who billsA physician, nurse practitioner, physician assistant, or clinical nurse specialist who is the continuing focal point for the patient’s primary care.
Who can supportAuxiliary personnel may furnish applicable service elements under general supervision; CMS allows employees, leased employees, or independent contractors of the billing provider.
Boundary to verifyThe practice must provide the required primary-care capabilities and consent. APCM is a monthly bundle, not a way to bill separately for every staff task.
TCMView billing and team boundaries
Who billsThe eligible billing practitioner is responsible for the transition and performs the required face-to-face visit and medical decision making.
Who can supportClinical staff may provide specified non-face-to-face transition work under general supervision.
Boundary to verifyDischarge setting, two-business-day contact, visit timing, medication reconciliation, and 30-day service-period rules all matter.
RPMView billing and team boundaries
Who billsAn eligible billing practitioner orders and oversees medically necessary physiologic monitoring.
Who can supportClinical staff may support treatment management under general supervision when the applicable code and incident-to rules permit it.
Boundary to verifyDevice and management codes have different requirements. CMS finalized a separately reportable initiating visit for 2027; its direct-employee rule for monitoring clinical staff begins in 2029.
RTMView billing and team boundaries
Who billsEligible billing practitioners, including therapists where Medicare therapy rules permit, may report applicable RTM codes.
Who can supportQualified staff or therapy assistants can support applicable services subject to code, therapy, and supervision rules.
Boundary to verifyTherapy-specific coding and assistant payment adjustments differ by code. RTM becomes an established-patient service in 2027 and requires a separately reportable initiating visit. The direct-employee rule begins in 2029.
BHI / CoCMView billing and team boundaries
Who billsAn eligible treating practitioner bills the appropriate general BHI or psychiatric CoCM service; billing rules vary by code and practitioner type.
Who can supportCare managers and other qualified team members perform defined components under the applicable supervision and team structure.
Boundary to verifyCoCM requires a psychiatric consultant and additional registry, review, and care-manager elements. It is not interchangeable with general BHI.
PCMView billing and team boundaries
Who billsAn eligible physician or qualified health care professional bills for management of one complex, high-risk condition.
Who can support99424/99425 count practitioner time; 99426/99427 describe clinical-staff time directed by the billing practitioner.
Boundary to verifyUse the code matching who actually performed the time. A single diagnosis without the required complexity, risk, care plan, and qualifying work is not enough.
PIN / CHIView billing and team boundaries
Who billsThe eligible practitioner who performs the required initiating visit bills the subsequent PIN or CHI service.
Who can supportQualified auxiliary personnel, including contracted navigators or community health workers, may furnish applicable work under general supervision.
Boundary to verifyPIN addresses a serious high-risk condition; CHI addresses social needs that interfere with diagnosis or treatment. Each has its own initiating, personnel, and documentation rules.
CPMView billing and team boundaries
Who billsA physician or other qualified health care professional reports the monthly chronic-pain management bundle.
Who can supportClinical team members may support care coordination, but the first 30 minutes for G3002 must be personally provided by the billing practitioner.
Boundary to verifyAn initial face-to-face visit, pain assessment, person-centered plan, required time, and applicable service elements must be documented.
MTMView billing and team boundaries
Who billsThe Part D plan sponsor establishes the medication-therapy-management program; payment arrangements are plan-specific.
Who can supportPharmacists or other qualified providers may furnish MTM according to sponsor requirements and contracts.
Boundary to verifyThis is not a general Original Medicare Part B physician-fee-schedule payment pathway for a practice.
PrimeVital’s role
We can help design workflows, coordinate U.S.-based clinical staffing where appropriate, track required evidence, and support the practice’s RCM team. The enrolled billing practitioner remains accountable for clinical decisions and claims. Staff working remotely or under contract are not automatically eligible for every code.
HOW PAYMENT WORKS
Allowed amount is not collected revenue.
CMS adjusts work, practice-expense, and malpractice relative value units by the locality's Geographic Practice Cost Index, then applies the conversion factor. California rates vary by Medicare payment locality. A county is a useful lookup, but the claim should be priced from the service location and current CMS locality files.
[(work RVU × work GPCI) + (PE RVU × PE GPCI) + (MP RVU × MP GPCI)] × conversion factor$33.4009CY2026 non-QP conversion factor$33.5675CY2026 QP conversion factor80% / 20%General Medicare and beneficiary split after deductible rules2%Sequestration generally applied to the Medicare portion
SELECTED REQUIREMENTS
Resolve the service elements before discussing the rate.
APCM
A monthly, non-time-based primary-care bundle. The billing practitioner must be responsible for primary care, serve as the continuing focal point, obtain consent, and furnish the required elements when clinically appropriate.
TCM
A 30-day period beginning on discharge, with interactive contact within two business days, a face-to-face visit within seven or 14 days depending on the code, and medication reconciliation on or before the visit.
RPM and RTM
Match the code to the actual device days, treatment-management time, real-time interactive communication, clinical purpose, and eligible billing practitioner. CY2026 added shorter-duration device and management options.
BHI and CoCM
General BHI and the psychiatric Collaborative Care Model are different. CoCM adds a behavioral health care manager, psychiatric consultant, registry, validated measures, and weekly caseload consultation.
MTM
99605-99607 have Physician Fee Schedule status X. Part D MTM is plan-sponsored and plan-specific; it should not be presented as a general Part B fee-schedule opportunity.
REPRESENTATIVE NON-FACILITY AMOUNTS
National reference and California locality range.
These eight Original Medicare amounts were rechecked against October 2026 RVUs, GPCIs and the California carrier file (RVU26D). The values happen to be unchanged from the July reference. They apply to October–December 2026 dates of service, subject to the exact claim circumstances. Use the county lookup for the broader code families.
| Code and service | National | California range |
|---|---|---|
| 99490Standard CCM, first 20 minutes | $66.13 | $68.53-$82.16 |
| G0557APCM for two or more qualifying conditions | $53.78 | $55.97-$67.49 |
| 99495TCM, moderate complexity | $220.11 | $230.35-$280.82 |
| 99496TCM, high complexity | $298.60 | $312.78-$381.30 |
| 99454RPM device supply, 16-30 qualifying days | $52.11 | $56.92-$74.83 |
| 99457RPM management, first 20 minutes | $51.77 | $54.38-$66.68 |
| 98977Musculoskeletal RTM device supply, 16-30 days | $51.44 | $56.19-$73.87 |
| 99484General behavioral health integration | $57.45 | $59.39-$70.71 |
Actual payment can change with site of service, QP status, deductible, secondary coverage, QMB protections, MIPS, sequestration, claim edits, medical necessity, documentation, and denials. Medicare Advantage and commercial rates require the practice's plan contract or fee schedule.
CONCURRENT BILLING
Use a caution table, not a blanket “yes” or “no.”
These selected CMS statements are useful orientation. They are not a complete edit matrix, and no combination is automatically billable without independent medical necessity and documentation.
| Combination | Public guidance |
|---|---|
| Standard and complex CCM | Do not report non-complex and complex CCM for the same patient in the same calendar month. |
| Practitioner CCM and staff CCM | Do not report 99491 or 99437 in the same month as 99487, 99489, 99490, or 99439. |
| CCM and TCM | CMS permits selected CCM codes during the 30-day TCM period when time and work are not counted twice. |
| RPM and RTM with CCM or TCM | CMS permits either RPM or RTM, but not both, concurrently with CCM or TCM. |
| APCM and bundled services | APCM incorporates CCM, PCM, TCM, and selected communication services. Confirm current same-practitioner and same-month rules before reporting separately. |
Before launch
Identify the legal entity, practitioner, specialty, site of service, and Medicare enrollment that will bill.Confirm Original Medicare or the exact plan and contract; never substitute a PFS amount for an MA or commercial rate.Verify eligibility, medical necessity, initiating-service, consent, established-patient, and frequency requirements.Configure evidence for time, device days, communication, care plans, and supervision before outreach.Check CPT, NCCI, MUE, MAC, payer, and CMS-model duplication rules.Test enrollment through claim response before scaling.PRIMARY SOURCES
Every public requirement should lead back to the source.
The complete PDF includes the rate-data build, version record, AMA notice, and additional source detail.
CMS · Chronic Care Management ServicesCMS · Advanced Primary Care Management ServicesCMS · Transitional Care Management ServicesCMS · Remote Patient MonitoringCMS · Therapy Code List 2026 Annual UpdateCMS · Behavioral Health Integration ServicesCMS · CY2026 Medicare Physician Fee Schedule Final RuleCMS · CCM billing FAQ: contracted clinical staff and U.S. locationCMS · October 2026 physician fee schedule release (RVU26D)CMS · CY2027 Physician Fee Schedule final rule
APPLY IT TO YOUR PRACTICE
Use the public guide for orientation, then verify the exact payer, population, and workflow.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com