Chronic Care
Management
Monthly reimbursement for care coordination your team is already delivering — no devices, no new workflows.
What Is Chronic
Care Management?
CCM reimburses providers for the non-face-to-face coordination that keeps chronically ill Medicare patients stable between visits — care plan management, medication reconciliation, and cross-provider communication.
Captures Existing Clinical Work
Your team is already making these calls. CCM creates a billing structure around effort you're delivering today.
Low Barrier to Entry
The only threshold is 20 minutes of documented clinical staff time per calendar month. Enrollment is immediate.
Built for Home-Based Care Populations
HBPC patients are among the most chronically complex in Medicare. Most already qualify — they just haven't had a platform designed to bill this service compliantly.
Common Qualifying Condition Pairs
From Eligible Patient
to Billed Claim.
Four steps — fully managed within Guardian's platform.
Identify & Enroll
Guardian surfaces eligible patients from your panel. Review and enroll in one click.
Document Consent
Verbal or written consent captured and time-stamped directly in Guardian before the first claim.
Build the Care Plan
Pre-populated templates for common condition combinations — ready to customize and deploy.
Track, Coordinate, Bill
Time logs automatically. When the monthly threshold is met, Guardian generates a compliant claim.
CPT Codes &
Billing Tiers
Standard and complex pathways scale revenue with patient complexity and physician involvement. Hover a card for details.
Standard CCM — First 20 Minutes
Standard CCM — Each Additional 20 Minutes
Complex CCM — First 30 Minutes (Physician)
Complex CCM — Each Additional 30 Minutes
Built for Home-Based
Care Complexity
Generic CCM platforms weren't designed for house call medicine. Guardian was. Hover a card for details.
Automatic Time Capture
Care Plan Templates
Multi-Provider Coordination Logs
Duplicate Billing Safeguards
One-Click Billing Reports
Medication Reconciliation
Know the Rules.
Avoid the Pitfalls.
CCM carries specific CMS documentation requirements. Guardian enforces these automatically — but your team should understand them.
Requirements
- Standard CCM (99490/99439) may be performed by clinical staff under general supervision — physician personal time not required.
- Complex CCM (99491) requires direct physician or QHP personal time. Clinical staff time does not count.
- Only one provider may bill CCM for a given patient per calendar month.
- Patient consent must be documented in the medical record before the first claim.
- An initiating face-to-face visit within the prior 12 months is required.
Common Mistakes
- Billing 99490 before consent is documented — consent must precede the first claim.
- Counting the same minutes toward both CCM and PCM — mutually exclusive per CMS.
- Using clinical staff time to satisfy the 99491 threshold — physician/QHP personal time only.
- Submitting CCM without a care plan covering all conditions, medications, and care team contacts.
- Including administrative time — scheduling, billing calls — in the 20-minute clinical threshold.
Common
Questions
Click a question to see the answer.
Yes — concurrently in the same month, provided time for each is tracked separately with no overlap. Guardian enforces this separation automatically.
Any condition expected to last ≥12 months placing the patient at significant risk of death, acute exacerbation, or functional decline. The patient must have at least two. Common examples: hypertension, diabetes, heart failure, COPD, CKD, depression.
When the patient requires substantial direct physician involvement. Key distinction: 99491 requires 30 min of physician personal time; 99490 requires 20 min of clinical staff time under general supervision.
No — consent remains valid until revoked. Best practice is to reconfirm at the annual AWV. Initial consent must inform the patient that only one provider may bill CCM per month.
Care plan development/revision, medication reconciliation, provider coordination, home health/community coordination, patient education, and psychosocial assessment. Administrative tasks do not count.
Guardian flags patients enrolled in CCM with another billing provider during claim preparation, preventing duplicate billing and protecting practices from CMS audit exposure.
Ready to Launch
CCM?
Guardian handles eligibility, consent, care plans, and billing — so your team can focus on patients, not paperwork.