Most clinics are overlooking two of Medicare’s most valuable reimbursement opportunities: Chronic Care Management (CCM) and Principal Care Management (PCM). These programs were created to pay clinics for the essential, between-visit work they already perform - reviewing medications, following up on symptoms, coordinating care, and helping patients manage complex conditions day to day. In most clinics, this work happens informally and goes completely unreimbursed. CCM and PCM finally formalize and compensate that effort, turning what has historically been “invisible work” into a reliable monthly revenue stream.

Despite this, many practices either don’t enroll patients at all or enroll only a small fraction of those who qualify. The gap isn’t due to lack of interest, it’s due to lack of infrastructure. Running a compliant CCM or PCM program requires consistent monthly outreach, structured follow-up calls, clear documentation, and precise time tracking. Most clinics simply don’t have the bandwidth to do this consistently while also maintaining full patient schedules.

That’s exactly where we come in. At Foresight Health, we run telehealth CCM and PCM programs end-to-end so clinics can offer these services without adding new staffing burdens or administrative tasks. We identify eligible patients, handle outreach and consent, conduct monthly telehealth check-ins, complete all documentation, track billable minutes, and prepare everything the clinic needs for Medicare billing. Practices benefit from the clinical and financial upside while our team manages the operational lift.

CCM: Chronic Care Management

Chronic Care Management reimburses clinics for providing ongoing support to patients who have two or more chronic conditions expected to last at least a year. These are some of the most common and complex Medicare patients—individuals living with diabetes, hypertension, COPD, congestive heart failure, chronic kidney disease, depression, dementia, neuropathy, or various combinations of these diagnoses. Their care needs span far beyond what can be addressed during periodic office visits.

CCM allows clinics to deliver consistent monthly follow-up, ensuring these patients do not fall through the cracks between visits. Through scheduled check-ins, medication reviews, symptom assessments, and care-plan updates, CCM gives clinics a structured way to provide proactive management rather than waiting for problems to escalate. This level of ongoing support stabilizes conditions, improves adherence, and reduces the risk of avoidable hospitalizations.

PCM: Deep Focus on One Complex Condition

While CCM looks broadly across a patient’s full set of chronic conditions, Principal Care Management focuses deeply on one single, high-risk chronic condition that requires regular monitoring or frequent treatment adjustments.

Neurology, in particular, is a natural fit for PCM. Patients managing Parkinson’s disease, multiple sclerosis, epilepsy, neuropathy, chronic migraine, or post-stroke complications often require frequent adjustments to medications, ongoing symptom tracking, and early detection of complications. PCM reimburses clinics for providing this focused oversight every month.

How Reimbursement Works

CCM and PCM use time-based CPT codes tied to the number of minutes spent on telehealth care management each month. Medicare reimburses for structured, documented time spent supporting a patient’s chronic condition outside of an in-person visit.

Every month our staff speaks with a patient, reviews medications, evaluates symptoms, coordinates with specialists, updates care plans, or reviews lab results, those minutes can count toward billable time. Below are the core codes clinics bill most often, along with their national average Medicare reimbursement amounts.

Who Is Eligible to Bill

Eligibility is often much broader than clinics assume and that’s part of why these programs are so underutilized.

CCM Eligibility

A patient must have:

• Two or more chronic conditions

• Expected to last at least 12 months

• Meaningful risk of morbidity or functional decline

• Documented informed consent

  
  

PCM Eligibility

A patient must have:

• One serious chronic condition

• Expected to last at least 3 months

• Ongoing physician or specialist supervision

• Documented informed consent

  
  

Most clinics discover that 70–85% of their Medicare population qualifies for CCM, and 25–40% qualifies for PCM. In neurology, that PCM percentage is often even higher.

What Counts as Billable Time

One of the biggest surprises to clinics is just how many routine clinical activities count toward billable CCM or PCM minutes. Medicare reimburses for nearly all non-face-to-face activities that support chronic condition management, including:

• Follow-up phone calls

• Reviewing labs, imaging, or specialist notes

• Medication reconciliation and adjustments

• Updating care plans

• Coordinating referrals

• Scheduling appointments

• Communicating with family or caregivers

• Reviewing remote monitoring data

• Documenting symptoms or clinical changes

• Educating patients on self-management

  
  

If it supports the patient’s chronic condition and happens outside of an in-person visit, it likely qualifies.

Documentation Requirements

Medicare reimbursement for CCM and PCM depends entirely on accurate, complete, and timely documentation. Every billed month must reflect genuine, ongoing management of the patient’s chronic condition, and the clinic must be able to demonstrate this through well-structured records.

A key component is the Comprehensive Care Plan, which must include all active diagnoses, current medications, symptom profiles, treatment goals, planned interventions, and clear self-management recommendations for the patient. This plan must remain accessible to anyone involved in the patient’s care and must be updated regularly as symptoms change, medications are adjusted, or new issues arise. When we manage CCM and PCM for clinics, we take responsibility for maintaining and updating this care plan continuously so it always reflects the patient’s current clinical status.

Alongside the care plan, Medicare requires precise, time-stamped activity logs. Every interaction that contributes to billable time must include the date, the length of the interaction, and a brief but specific description of what occurred. This includes reviewing lab results, adjusting medications, coordinating with specialists, documenting patient concerns, or providing self-management guidance. Any ambiguity in these notes can lead to downcoded or denied claims, which is why our documentation team records every action in real time and ensures that each entry meets Medicare’s standards.

Medicare also mandates that enrolled patients must have 24/7 access to clinical support, meaning they must be able to reach a qualified individual outside of normal office hours. Most clinics fulfill this requirement through a triage line or on-call service, but the access must be clearly documented. Our workflows integrate directly with the clinic’s existing after-hours systems so the requirement is met without additional staffing.

Another essential component is informed consent, which must be obtained and documented once every twelve months. Consent can be verbal or written, but the record must show that the patient understood the nature of the service, the potential cost-sharing requirements, and their ability to opt out at any time. We handle the entire consent process, from patient education to documentation, ensuring that every enrolled patient meets Medicare’s criteria.

Finally, Medicare requires continuity of care, meaning an overseeing clinician, typically the patient’s primary provider or managing specialist, must remain responsible for directing the program. This clinician does not need to conduct the monthly calls personally, but they must stay informed through documented updates and remain clinically accountable for the care plan. Our system routes all updates, symptom changes, and escalations back to the overseeing provider in an organized, digestible format so continuity is always maintained.

Together, these elements form the core of Medicare compliance for CCM and PCM. Without them, claims cannot be billed or may be rejected. We manage every part of this documentation process on behalf of clinics, ensuring that each enrolled patient is fully compliant and that every month’s activity is billable, traceable, and ready for audit at any time.

How Clinics Actually Get Paid

Medicare reimburses CCM and PCM on a monthly cycle, meaning the clinic receives payment for each patient every month that the program requirements are met. Unlike fee-for-service encounters that depend on scheduling, no-shows, or visit volume, CCM and PCM reimbursement is tied to time thresholds and documentation standards. Once the clinic completes the required number of minutes and maintains compliant records, the clinic can submit the CCM or PCM code just like any other CPT code. Medicare processes these claims through standard billing channels, and payment is issued on the clinic’s regular reimbursement schedule.

What makes this model uniquely valuable is its predictability. Because patients qualify for these programs based on ongoing chronic conditions, not isolated episodes of care, the same patients can be billed month after month as long as the necessary work is completed. This transforms what is often uncompensated background work into a recurring revenue stream. Clinics begin to see revenue stabilize, smoothing out the variability in traditional appointment-driven income. Over time, CCM and PCM become reliable financial pillars for many outpatient practices.

Why CCM & PCM Matter Now More Than Ever

These programs do far more than stabilize clinic revenue. They fundamentally improve the way care is delivered. They support patients during the long stretches between appointments, help clinicians catch problems early, reduce avoidable hospitalizations, and improve medication adherence. Most importantly, they turn the quiet, behind-the-scenes work your clinic already does into a structured, reimbursable model of proactive care.

With Foresight Health running the operations end-to-end, clinics benefit from higher quality, higher compliance, and higher reimbursement without needing additional staff.

Conclusion

CCM and PCM are among the highest-ROI programs available to Medicare clinics - financially and clinically. By reimbursing the essential work teams already perform, they help clinics deliver more continuous, coordinated, and proactive care, all while adding tens of thousands of dollars in stable monthly revenue. For practices willing to operationalize them correctly, CCM and PCM don’t just enhance patient care, they become foundational to long-term sustainability.