Medicare care-management programs, explained
What each program is, who qualifies, and what it takes to bill it compliantly.
Chronic Care Management
A monthly non-face-to-face service for patients with two or more chronic conditions, covering care planning, 24/7 access, and coordination between visits.
Codes: 99490, 99439, 99491, 99437, 99487, 99489, G0506
View programBehavioral Health Integration
Monthly codes for integrating behavioral health care into a primary care or specialty practice, for patients with a behavioral health condition being treated by the billing practitioner.
Codes: 99484, G0323, G0570
View programCommunity Health Integration
A monthly service for connecting patients to community-based resources that address unmet social needs, such as housing, food, or transportation, that are interfering with an existing medical treatment plan.
Codes: G0019, G0022
View programPrincipal Care Management
A monthly care-management service for a single, high-risk chronic condition, aimed at specialists and generalists managing one complex problem rather than a whole patient panel.
Codes: 99424, 99425, 99426, 99427
View programChronic Pain Management
A monthly bundled service for patients with chronic pain lasting longer than 3 months, covering a person-centered care plan, medication management, and coordination with behavioral health and rehab providers.
Codes: G3002, G3003
View programRemote Physiologic Monitoring
Codes for supplying a connected device that captures physiologic data (like blood pressure or weight) and for the clinical staff time spent reviewing and acting on it each month.
Codes: 99453, 99454, 99445, 99457, 99458, 99470
View programRemote Therapeutic Monitoring
Codes for monitoring musculoskeletal, respiratory, or cognitive behavioral therapy adherence and response, using patient-reported or device-captured non-physiologic data.
Codes: 98975, 98976, 98977, 98978, 98984, 98985, 98986, 98980, 98981, 98979
View programAnnual Wellness Visit
A yearly, conversation-based preventive visit to build or update a personalized prevention plan, distinct from a routine physical exam, plus an optional same-day advance care planning discussion.
Codes: G0438, G0439, 99497, 99498
View programAdvanced Primary Care Management
A flat, three-tier monthly service introduced in CY2025 that bundles the care-management work of CCM, PCM, and TCM into one code, with no minutes to track.
Codes: G0556, G0557, G0558
View programTransitional Care Management
A 30-day bundled service for the first outpatient contact and follow-up visit after a patient is discharged from an inpatient or institutional setting back to the community.
Codes: 99495, 99496
View programFAQ
What is Chronic Care Management (CCM) and what are its billing codes?
CCM is a monthly non-face-to-face service for patients with two or more chronic conditions, covering care planning, 24/7 access, and coordination between visits. Associated billing codes include 99490, 99439, 99491, 99437, 99487, 99489, and G0506.
What is Principal Care Management (PCM)?
PCM is a monthly care-management service for a single, high-risk chronic condition, aimed at specialists and generalists managing one complex problem. Associated codes include 99424, 99425, 99426, and 99427.
What is Advanced Primary Care Management (APCM)?
APCM is a flat, three-tier monthly service introduced in CY2025 that bundles the care-management work of CCM, PCM, and TCM into one code, with no minutes to track. Associated codes are G0556, G0557, and G0558.
What codes are associated with Chronic Pain Management (CPM)?
Chronic Pain Management (CPM) is a monthly bundled service for patients with chronic pain lasting longer than 3 months. Associated billing codes are G3002 and G3003.