Find eligible patients
We build an eligible list from your EHR and claims data and agree who is approached first.
CCM gives patients with two or more chronic conditions a named point of contact between visits — a care plan they can follow, a monthly check-in, and help with medications, referrals and appointments. We run the outreach, scheduling, documentation and time tracking so your clinical team can stay focused on decisions.
Eligibility is confirmed against your own population before a pilot group is approached.
Two or more chronic conditions expected to last at least 12 months, or until death
Conditions that place the patient at significant risk of decline, exacerbation or death
Verbal or written consent documented before services begin
A comprehensive care plan established, shared and revised as needed
Your clinicians keep every clinical decision. We run the operations around them.
We build an eligible list from your EHR and claims data and agree who is approached first.
Approved scripts introduce the program, capture consent and set the first check-in.
Coordinators review goals, medications and barriers, and update the care plan.
Clinical concerns are routed to your clinicians the same day through agreed paths.
Time, activities and care-plan changes are logged for review before claims go out.
Care-plan approval, clinical assessment, medication changes and supervision remain with your physicians and qualified clinical staff.
Listed as published for calendar year 2026 under the Medicare Physician Fee Schedule. Requirements, documentation rules and payer policies change — confirm current CMS and payer guidance with your billing team. Carevory does not guarantee reimbursement. CCM billing codes
| Code | What it covers |
|---|---|
| 99490 | First 20 minutes of clinical staff time, per calendar month |
| 99439 | Each additional 20 minutes of clinical staff time |
| 99491 | First 30 minutes personally provided by a physician or QHP |
| 99437 | Each additional 30 minutes by a physician or QHP |
| 99487 | Complex CCM, first 60 minutes of clinical staff time |
| 99489 | Complex CCM, each additional 30 minutes |
Carevory does not guarantee reimbursement. Confirm current CMS and payer guidance with your billing team before you bill.
The same minutes are never counted toward two programs — time is logged against one at a time.
What practices ask before launching CCM.
Yes, the two are commonly combined in the same month. The same minutes cannot be counted toward both, so time is logged against one program at a time.
No. Coordinators handle outreach, scheduling, documentation and routing. Clinical work is performed by your clinicians or by qualified clinical staff under your supervision, as contracted.
Your clinicians, or qualified clinical staff working under your supervision and protocols where contracted. Carevory runs the operations around them: eligibility, enrollment, outreach, scheduling, queues, documentation and reporting.
No. Payer rules, documentation and clinical decisions determine payment. We help you meet program requirements and give you clean records for billing review.
Tell us about your patient population, systems and staffing. We'll scope a pilot group, the workflow and the reporting you'd see each month.
Business inquiries only. Please don't include patient information.