CCM
Chronic Care Management
A monthly care plan conversation for every patient with two or more chronic conditions.
Who it is for
Patients with 2+ chronic conditions expected to last 12 months.
What the patient experiences
Step 1
Getting started
Their doctor orders the program and they give consent.
Step 2
Day to day
A registered nurse calls monthly to review their care plan and goals.
Step 3
Follow up
Their care plan stays current and their doctor stays informed.
Stock photography. Not Aetos staff or patients.
What Aetos does, and what your practice does
Your practice
- Orders the service
- Makes clinical decisions
- Reviews escalations
- Keeps billing authority
Aetos
- Enrollment
- Devices
- Monitoring
- Outreach
- Documentation
- Threshold tracking
2026 codes
| Code | Description | Approx. rate |
|---|---|---|
| 99490 | First 20 minutes of clinical staff time | $66 |
| 99439 | Each additional 20 minutes | $50 |
| 99487 | Complex CCM, first 60 minutes | $144 |
Approximate 2026 Medicare national averages. Actual payment varies by locality and payer. Not a guarantee of reimbursement. Codes and rates are pending review by Aetos clinical and billing leads before launch.
Requirements we track for you
- Documented consent
- Comprehensive care plan
- 20 minute time thresholds
- Documentation of time and activities
Questions
Who qualifies?
Patients with two or more chronic conditions expected to last 12 months or more, as determined by their physician.
Who calls the patient?
Aetos clinical staff, led by a registered nurse, under your practice's direction.
Can CCM run alongside RPM?
Practices often run both. Billing rules for each program apply, and your billing lead should confirm combinations.
What does the practice do?
Orders the service, reviews escalations and keeps billing authority.
Explore other programs
01RPM
Remote Patient Monitoring
Cellular cuffs, scales and meters send readings every day; our nurses review them.
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02RTM
Remote Therapeutic Monitoring
Therapy adherence and recovery tracking, supported by PT, OT, NP or PA staff.
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03BHI
Behavioral Health Integration
Depression and anxiety support built into primary care.
Explore program
04CoCM
Collaborative Care (CoCM)
A behavioral care manager plus a psychiatric consultant we provide.
Explore program
Stock photography. Not Aetos staff or patients.
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