CCMChronic Care Management
Two or more qualifying chronic conditions
Monthly time based
Request an assessment 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.
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.
ProgramClinical useBilling structure
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
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.
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.
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 are CY2026 Original Medicare allowed amounts calculated from CMS data. They are not a quote, coverage decision, or estimate of collections.
Code and serviceNationalCalifornia 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.
CombinationPublic guidance
Do not report non-complex and complex CCM for the same patient in the same calendar month.
Do not report 99491 or 99437 in the same month as 99487, 99489, 99490, or 99439.
CMS permits selected CCM codes during the 30-day TCM period when time and work are not counted twice.
CMS permits either RPM or RTM, but not both, concurrently with CCM or TCM.
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 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.
Choose how to connect
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