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Chronic care management is essential for many chronic gastrointestinal disorders. This article will introduce how to utilize chronic care management current procedural terminology (CPT) codes to assist in developing an organized process to care for your patients. The chronic care management (CCM) code set includes a structured administrative support system and a comprehensive care plan. This includes a structured recording of patient health information, comprehensive electronic care plans, and managing transitions of care to specialists or tertiary care centers.

Chronic care management codes require 2 chronic diseases that will be in effect for over 1 year or until the death of the patient. This CPT code set encourages a programmatic framework for reimbursement and structured care for the ongoing needs addressed with patients with chronic illness who require frequent points of contact outside of office visits. Once the patient is identified as meeting the criteria, consent needs to be obtained to ensure understanding of the utilization of the codes and confirm awareness of potential cost-sharing. Then an initiating visit is done-this is either in person for those who have not been seen in the prior 12 months, or via phone if they have been seen in the past year. These visits are scheduled monthly to ensure the patient is receiving comprehensive follow-up and care to avoid hospitalization or gaps in care.

The comprehensive care plan should include personalized goals of care for the patient and address any needs identified for any social determinants of health. The CPT codes can be billed once every 28 days and is inclusive of the time for all the non-face to face care documented over that time frame. It is important to note that the CCM codes can only be reimbursed to one provider who is caring for the patient, so the patient’s participation in one program should be emphasized. The example below is a case study of a scenario on how to utilize Chronic Care Management Codes. This article is meant to be an introduction to the CCM codes. This is not an exhaustive list of the coding requirements. Refer to the references provided below before setting up a CCM program.

CHRONIC CARE MANAGEMENT CODES

Chronic Care Management Services:

Patient Background

• Name: Ms. A.B. 59-year-old female
• Chronic Conditions:
  • Ulcerative Colitis without complications – ICD-10 K51.90
  • Gastroesophageal Reflux Disease without esophagitis – ICD-10 K21.9
• Consent: Obtained 1/2025
• Care Team: Dr. Jones (Gastroenterologist), Sue Smith, Gastroenterology NP, Primary Care Physician, and Clinical Pharmacist.

Clinical Encounter (August 2025)
Total Provider Time: 36 minutes (documented, non-face-to-face)
Activities performed personally by the physician/provider:

Direct phone call with patients. Discussed:

• GERD: symptoms stable, occasional mild heartburn after coffee.
• Ulcerative Colitis: 2–3 formed stools/day, no rectal bleeding, no abdominal pain.
• Medication adherence reviewed (pantoprazole, mesalamine).

Reviewed recent colonoscopy pathology results and prior labs. Confirmed no dysplasia, mild chronic inflammation consistent with stable disease.

Adjusted medication plan—reinforced continuation of mesalamine maintenance therapy, advised trial of pantoprazole dose taper if reflux remains mild.

Updated care plan in EMR (problem list, goals of care, flare prevention strategies, GERD lifestyle modifications).

Coordinated follow-up plan—scheduled 1-month GI follow-up, recommended repeat colonoscopy in 2 years, routed note to PCP for continuity.

Goals of Care

• Maintain 2-3 formed stools per day
• Continue Mesalamine and Pantoprazole as directed
• Notify the office if symptoms of flares occur
• Schedule Dermatology screening appointment due 12/2025. Schedule by 10/2025
• Recommend annual labs completed by 12/2025

Documentation Key Points

• Date: August 15, 2025
• Code: CPT 99491 – Chronic Care Management, provided personally by a physician or nurse practitioner or physician assistant (APP), 30 minutes
• Chronic Conditions Managed:
  • Ulcerative Colitis (K51.90)
  • GERD (K21.9)
• Total Physician/Provider Time: 36 minutes documented
• Activities: Direct patient communication, review of test results, medication management, care plan revision, coordination with PCP
• Patient Status: Stable on therapy; no flares; GERD well-controlled with minor lifestyle adjustments

Key Point: Unlike 99490/99439 (staff-driven CCM), 99491 requires physician/QHP personally providing ≥30 minutes in the calendar month. Documentation must explicitly show physician/APP time and actions taken. Clinical staff documentation requires separate documentation to capture the administrative time and clinical staff services provided during each calendar month.

REFERENCES

1. MLN909188 – Chronic Care Management Services. CMS.gov (2025), (available at ).

1. Chronic Care Management Provider(s) Checklist. CMS.gov (2023) (available at ).

Authors

Jill Olmstead, DNP, ANP-BC, CDIP, CCS-P, FAANP
Dr. Olmstead is an Adult Nurse Practitioner at Providence Health in Fullerton, California, with over 15 years of experience specializing in gastroenterology. She is a former member of the 91ÊÓƵReimbursement Committee and currently serves on the 91ÊÓƵAdvanced Practice Providers (APP) Committee. Dr. Olmstead has also represented the American Nurses Association as a Primary Delegate to the AMA CPT Editorial Panel and Health care Professionals Advisory Committee (HCPAC).

Rebecca McCollaum, MSN, FNP-C
Rebecca McCollaum is the National Director of Chronic Care Management for GI Alliance. She has been an NP since 2007 practicing in cardiology and gastroenterology. She pioneered a remote Inflammatory Bowel Disease medical home in Arizona in 2018 which transitioned into a Chronic Care Management program in 2020 with GI Alliance.