Run CCM in-house with AI workflows
Cynnvi lets your existing care team operate Chronic Care Management end to end, while AI reduces the outreach, documentation, task-management, and time-capture work that normally eats up a coordinator's day.
How Cynnvi runs CCM, month to month
Identify and enroll
Cynnvi surfaces patients with two or more qualifying chronic conditions, then AI voice outreach handles enrollment calls and captures consent.
AI voice outreach for enrollment is included, not billed as a separate line item.
Generate the care plan and tasks
A patient-specific care plan is drafted from the chart, then turned into a prioritized monthly task list for staff to review and approve.
Tasks come from the approved care plan, recent notes, and each call, with the source shown for every suggestion.
Reach patients
Included AI voice outreach calls patients on the worklist, warm-transfers anyone available to speak, and schedules the rest for a staff call.
Extended Workflow Automation add-on: Automate Care Tasks can also check in by SMS between calls, and route any reply that needs staff into the same worklist.
Capture human work and time
Every minute of clinical staff time is captured automatically from real EHR activity and traced back to the specific note, order, or referral behind it.
Extended Workflow Automation add-on: AI Receptionist adds inbound patient calls to the same worklist, so the staff follow-up they generate still gets captured and counted toward CCM.
Draft documentation
As soon as a staff call ends, the AI Scribe drafts the clinical note. Staff confirm it, then it's written back to the chart.
Prepare the monthly billing record
Approved time, documentation, and consent are assembled into a monthly billing record with a suggested CCM code, ready for staff sign-off.
Who qualifies
- Patient has two or more chronic conditions expected to last at least 12 months or until death
- Those conditions place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline
- Patient gives consent (verbal is acceptable, must be documented) to receive CCM on a monthly basis, understanding any applicable cost-sharing, and can stop the service at any time
- Only one practitioner or practice can bill CCM for a given patient in a given month
Codes at a glance
| Code | What it covers | Threshold | Approx. payment | Details link |
|---|---|---|---|---|
| 99490 | Non-complex CCM, first 20 minutes of clinical staff time, per calendar month | 20 minutes clinical staff time | ~$66 | Details → |
| 99439 | Non-complex CCM add-on, each additional 20 minutes (up to 2 units per month) | Each additional 20 minutes | ~$50 | Details → |
| 99491 | Non-complex CCM, first 30 minutes of physician/QHP time, per calendar month | 30 minutes physician/QHP time | ~$89 | Details → |
| 99437 | Non-complex CCM add-on, each additional 30 minutes of physician/QHP time | Each additional 30 minutes physician/QHP time | ~$63 | Details → |
| 99487 | Complex CCM, first 60 minutes of clinical staff time, per calendar month | 60 minutes clinical staff time, moderate-to-high complexity decision making | ~$144 | Details → |
| 99489 | Complex CCM add-on, each additional 30 minutes | Each additional 30 minutes | ~$78 | Details → |
| G0506 | Comprehensive care plan, initiating visit add-on (billed once) | Billed once, at the visit that establishes CCM | ~$66 | Details → |
Approximate CY2026 Medicare Physician Fee Schedule national non-facility payment benchmark for non-QP clinicians, before geographic, sequestration, and claim-specific adjustments. Actual reimbursement varies by locality, practitioner status, payer, and billing circumstances. Verify the applicable amount with CMS or your Medicare Administrative Contractor.
What's required to bill
- Documented patient consent to CCM, including any applicable cost-sharing
- A comprehensive, patient-centered care plan, created or revised and shared with the patient and care team, accessible electronically
- 24/7 access to the care team for urgent chronic care needs, including continuity with a designated care team member
- Management of care transitions between providers and settings
- Coordination with home- and community-based clinical service providers
- An initiating visit for new patients, or those not seen by the billing practitioner within the past year
- Only one practitioner bills CCM per patient per calendar month
Documentation checklist
- Signed or verbally-documented CCM consent in the chart
- A written, current care plan accessible to the whole care team
- Time log showing clinical staff time (99490/99439/99487/99489) or physician/QHP time (99491/99437) for the month
- Evidence of 24/7 access capability and care coordination activity performed during the month
- For complex CCM (99487/99489): documentation supporting moderate-to-high complexity medical decision making and the 60-minute (or greater) time threshold; the care plan itself only needs to be established, implemented, revised, or monitored that month, a substantial rewrite isn't required
Built for audit-ready compliance, with a human always in the loop
- Every AI-drafted note, task, and time entry is reviewed and approved by clinical staff before it counts toward billing, nothing is submitted automatically.
- Time capture traces back to the specific chart activity (note, order, or referral) behind it, producing an audit trail instead of a self-reported estimate.
- Staff attest to the accuracy of captured time and documentation before it's included in the monthly billing record.
- A signed Business Associate Agreement (BAA) is included, covering how protected health information is handled.
Common billing mistakes
- More than one practitioner or practice billing CCM for the same patient in the same month
- Billing complex CCM (99487) without medical decision making that actually supports moderate-to-high complexity
- Billing the add-on code (99439, 99489, or 99437) without first meeting the base code's time threshold
- No documented consent, or no accessible written care plan
- Mixing clinical staff time and physician/QHP time under the wrong code family (99490/99439 vs. 99491/99437)
- Billing CCM and APCM concurrently for the same patient and period
Why clinics run CCM with Cynnvi, not a vendor
EHR-embedded workflow
Cynnvi opens from the patient's chart in the EHR your clinic already uses. No separate portal, no new login.
Clinic-operated, not outsourced
Your own staff run CCM with Cynnvi's help. The program isn't handed off to a third-party call center.
No per-patient fee
One flat monthly price per clinic covers the program, regardless of how many patients are enrolled.
FAQ
Is this a CCM platform we manage ourselves, or an outsourced CCM vendor?
Cynnvi is software your own clinical staff use, not an outsourced CCM vendor or call center. Your team enrolls patients, reviews AI-drafted work, and stays the clinical decision-maker throughout.
Do we need a separate login or portal?
No. Cynnvi opens from inside the patient's chart in the EHR you already use, so staff don't need to switch between systems to run CCM.
Is there a per-patient fee?
No. Cynnvi is priced per clinic per month, not per enrolled patient, so growing your CCM panel doesn't change the price.
How does time capture work, and can we trust it for billing?
Time is captured automatically from real EHR activity (chart views, orders, referrals) and call duration, with every entry traceable to the specific action behind it. Staff review and approve captured time before it's used in the monthly billing record.
Does the AI replace our care coordinators?
No. AI drafts documentation, suggests tasks, and handles voice outreach, but staff review and approve everything before it's finalized. The goal is less write-up and outreach work for your existing team, not fewer staff.
Which EHRs does this work with?
Cynnvi supports Athenahealth, Aprima, DrChrono, eClinicalWorks, Elation, MDland, NextGen Enterprise, Office Ally EHR 24/7, Practice Fusion, and TouchWorks. See our integrations page for details on your EHR.
How is this different from generic CCM software or a billing platform?
Many CCM platforms track time and documentation manually. Cynnvi automates the outreach, documentation, task generation, and time capture around that workflow, so staff spend less time on data entry and more time on patient care.
Can CCM be billed alongside Advanced Primary Care Management (APCM)?
No. APCM incorporates the same underlying service elements as CCM, so CMS does not permit billing both concurrently for the same patient during the same period.
What's the difference between non-complex and complex CCM?
Complex CCM (99487/99489) is distinguished primarily by moderate-to-high complexity medical decision making and a higher, 60-minute time threshold. Since a 2020 CMS policy change, the care-planning element is satisfied whenever the care plan is established, implemented, revised, or monitored, it doesn't require a substantial rewrite of the plan that month. Non-complex CCM (99490/99439, or the physician-time equivalents 99491/99437) doesn't require that level of decision making and starts at a lower time threshold.
Can more than one doctor bill CCM for the same patient?
No. Only one practitioner or practice may bill CCM for a given patient in a given calendar month, even if the patient sees multiple specialists.
Is a face-to-face visit required to start CCM?
An initiating visit is required for new patients, or for patients the billing practitioner (or another practitioner in the same practice) hasn't seen within the past year. G0506 pays for the extra work of establishing the comprehensive care plan at that visit.