Care management services are more than a revenue opportunity. Done right, they drive measurable improvements in patient outcomes, reduce the total cost of care, and strengthen provider-patient relationships. The best part? They often represent activities your target customers are already doing but not getting paid for *yet*.
But the regulatory underpinnings—especially the alphabet soup of CPT codes and billing elements payors ACTUALLY require—can be daunting. So daunting, in fact, that the initial draft of this post was over 16 pages and 15,000 words long. Rather than making you weed through all of that on your own, this article starts with the basics of services designated as “Care Management Services” under Medicare: what each code set addresses, why it matters, and pro tips to help you identify your paths to success. Expect more detail on key regulatory concepts like clinical staff qualifications, supervision requirements, etc.) and specific billing requirements in future publications.
Bookmark this page to come back to when adding new functions to your technology or looking for the next opportunity to unlock for your customers and their patients.
** This article includes the codes we see most often in the digital health space and does not address all care management categories. If you’re looking for information on a specific topic, feel free to use the links below to jump to one of the following sections:
- Advanced Primary Care Management (APCM)
- Chronic Care Management (CCM)
- Complex Care Management (Complex CCM)
- Principal Care Management (PCM)
- Remote Physiologic Monitoring (RPM)
- Remote Therapeutic Monitoring (RTM)
- Behavioral Health Integration (BHI) & Psychiatric Collaborative Care Management (CoCM)
- Principal Illness Navigation (PIN)
- Community Health Integration (CHI)
Advanced Primary Care Management (APCM)
Background
APCM services—first introduced for Medicare fee-for-service reimbursement in 2025—encompass a comprehensive approach to primary care, integrating elements from existing care management services like CCM, PCM, and TCM, along with communication technology-based services like virtual check-ins. Unlike traditional codes, APCM is not time-based, shifting the focus of care management from time tracking to adding value and beginning to bridge the gap between fee-for-service and value-based reimbursement.
CPT Codes
- G0556: APCM for patients with one chronic condition.
- G0557: APCM for patients with two or more chronic conditions.
- G0558: APCM for patients with two or more chronic conditions who are Qualified Medicare Beneficiaries.
Who Can Bill for APCM
Physicians or NPPs (NPs, PAs, CNMs, CNSs that serve as (or will serve as) a centralized “hub” for comprehensive primary care.
Pro Tips
- APCM is a good fit for providers already using care management platforms, as it enables operational efficiency by consolidating multiple codes into one.
- APCM precludes billing for certain other care management codes.
- CMS explicitly identifies the ways in which technology can support all 13 service elements required for APCM, from risk stratification to enhanced patient communication to call centers with automated escalation workflows.
- Monthly billing offers predictable, recurring revenue.
Chronic Care Management (CCM)
Background
CCM involves non-face-to-face services provided to Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months or until the patient's death, which place the patient at significant risk of death, acute exacerbation, or functional decline.
CCM CPT Codes
- 99490: Initial 20 minutes of non-complex CCM provided by clinical staff.
- 99439: Each additional 20 minutes per month provided by clinical staff.
- 99491: Initial 30 minutes of CCM services provided personally by the billing provider.
- 99437: Each additional 30 minutes per month provided personally by the billing provider.
Who Can Bill for CCM
Physicians and NPPs (including NPs, PAs, CNMs, CNSs).
Pro Tips
- CCM is already widely adopted among providers, making it easier for digital health companies to educate current and potential customers.
- Compatible with, and complementary to, remote monitoring.
- Monthly billing offers predictable, recurring revenue.
- Opportunity for digital health companies to relieve admin burden by automating patient outreach, time tracking, and documentation.
Complex Chronic Care Management (Complex CCM)
Background
Complex CCM is an advanced form of Chronic Care Management designed for patients with two or more chronic conditions who require moderate or high complexity medical decision-making and more intensive care coordination.
Complex CCM CPT Codes
- 99487 – Initial 60 minutes of non-face-to-face clinical staff services per calendar month.
- 99489 – Each additional 30 minutes of clinical staff time.
Who Can Bill for Complex CCM
Physicians and NPPs (including NPs, PAs, CNMs, CNSs).
Pro Tips
- Compatible with, and complementary to, remote monitoring.
- Monthly billing offers predictable, recurring revenue.
- Complex CCM requires documentation of moderate/high complexity medical decision-making, medication management, and care coordination. Digital health companies can mitigate the administrative burden of these heightened requirements through documentation and workflow automation.
- Some payers outside of Medicare look at billing Complex CCM as an indicator of patient complexity, justifying higher prospective payments or shared savings distributions in value-based contracts, offering potential additional upside for your customers.
Principal Care Management (PCM)
Definition
Principal Care Management (PCM) covers ongoing clinical care and coordination for a single high-risk chronic condition that is expected to last at least three months. PCM was created to support specialty providers (e.g., cardiology, pulmonology, oncology, ophthalmology, etc.) in managing patients who have recently experienced an exacerbation of a single condition and require additional, sometimes short-term, support.
PCM CPT Codes
- 99424 – Initial 30 minutes of PCM services personally performed by the billing provider.
- 99425 – Each additional 30 minutes per month of PCM services personally performed by the billing provider.
- 99426 – Initial 30 minutes of clinical staff time.
- 99427 – Each additional 30 minutes of clinical staff time.
Who Can Bill for PCM
Physicians and qualified healthcare professionals (NPs, PAs, CNSs, CNMs).
Pro Tips
- PCM cannot be billed by the same provider in the same month as CCM or Complex CCM.
- PCM tends to be underutilized to date. Digital health companies can help build awareness by developing automated patient identification algorithms (e.g., single-disease registries) to surface eligible PCM patients consistently.
- Monthly billing offers predictable, recurring revenue.
Remote Physiologic Monitoring (RPM)
Definition
Remote Physiologic Monitoring involves the collection and interpretation of physiologic data (like blood pressure, glucose levels, or weight) from patients between visits, typically through connected medical devices that automatically transmit data to a patient’s care team. RPM helps providers identify exacerbations early, avoid unnecessary hospital visits, and make changes to a patient’s care plan in real time.
RPM CPT Codes
- 99453 – Initial setup and patient education on use of equipment.
- 99454 – Supply of device(s) with daily recordings or programmed alerts for each 30-day period.
- 99457 – Initial 20 minutes of clinical staff/physician/other qualified health care professional time in a calendar month, requiring interactive communication with the patient or caregiver.
- 99458 – Each additional 20 minutes.
Who Can Bill for RPM
Physicians and qualified healthcare professionals (NPs, PAs, CNSs, CNMs).
Pro Tips
- Digital health companies with connected devices or passive monitoring platforms can build strong recurring revenue streams here.
- Devices must meet the definition of a “medical device” under the FD&C Act, but do not necessarily require FDA clearance.
- Digital health companies can support clinical RPM programs by building workflows that automate data collection and analysis, flag clinical alerts, trigger timely outreach to patients, and automate billing for providers.
- Monthly billing offers predictable, recurring revenue.
- Using RPM to monitor patient data can help identify patients who may be a good fit for higher-complexity services like CCM or PCM.
Remote Therapeutic Monitoring (RTM)
Definition
Remote Therapeutic Monitoring (RTM) is a set of CPT codes that allow for the remote collection and monitoring of non-physiologic data, such as therapy adherence or therapy response, related to the musculoskeletal system, the respiratory system, or a cognitive behavioral therapy program. RTM is designed for use by providers involved in therapeutic services, including physical therapists and non-physician practitioners.
RTM CPT Codes
- 98975 – Initial setup and patient education on equipment (one-time code).
- 98976 – Monthly device supply for monitoring respiratory system status.
- 98977 – Monthly device supply for monitoring musculoskeletal system status.
- 98978 – Monthly device supply for monitoring CBT.
- 98980 – Initial 20 minutes of RTM treatment management services rendered by clinical staff/physician/other qualified health care professional in a calendar month, requiring interactive communication with the patient or caregiver.
- 98981 – Each additional 20 minutes of RTM treatment management services.
Who Can Bill for RTM
- Physicians and NPPs (NPs, PAs, CNMs, CNSs)
- Physical therapists, clinical psychologists, occupational therapists, and speech-language pathologists.
Pro Tips
- Ideal for gamified and/or care management platforms focused on physical therapy, pulmonary rehab, pain management, and behavioral health interventions.
- Unlike RPM, RTM allows for patient self-reported data — as long as it is collected through a “medical device” (e.g., software as a medical device, connected apps, sensor-enhanced braces).
- Digital health companies can use RTM to improve patient adherence through automated reminders and daily patient prompts.
- Monthly billing offers recurring revenue.
- Like RPM, data must be collected via a device that meets the definition of a “medical device” under the FD&C Act, which does not necessarily require FDA clearance.
Behavioral Health Integration (BHI)
Definition
Behavioral Health Integration (BHI) refers to incorporating behavioral health treatment, including options for both general behavioral health and psychiatric care, into the broader primary care setting through collaboration among inter-disciplinary care teams.
BHI & CoCM Codes
- 99484 – General BHI care management services, 20 minutes of clinical staff time per month.
- G0323 – 20+ minutes of clinical psychologist or social worker time providing general BHI.
- 99492 – First 70 minutes of behavioral health care manager time providing CoCM services in the first calendar month.
- 99493 – Subsequent psychiatric collaborative care management, first 60 minutes of behavioral health care manager time providing CoCM services in each month following the initial month.
- 99494 – Each additional 30 minutes of behavioral health care manager time providing CoCM services in any month.
- G2214 – First 30 minutes in a month of behavioral health care manager time providing initial or subsequent CoCM (use if time requirements for 99492 or 99493 are not met).
Who Can Bill for BHI
- Physicians and NPPs (NPs, PAs, CNMs, CNSs), typically in a primary care setting
Pro Tips
- Digital health companies can support BHI and reduce admin burden on billing providers through electronic tools for behavioral health assessments, patient journaling, patient segmentation, and integrated communication among care team members.
- Monthly billing provides predictable, recurring revenue.
- Payors outside of Medicare increasingly view BHI and CoCM as essential to success in value-based care models.
Principal Illness Navigation (PIN)
Definition
Principal Illness Navigation (PIN) services include care navigation activities for patients with high-risk, serious illnesses. These services are aimed at helping patients understand their condition, access community resources, and adhere to treatment — especially in the face of complex health and social challenges. Like most other care management codes, PIN codes are intended for auxiliary personnel (not clinicians) working under general supervision.
PIN Codes
- G0023 – Initial 60 minutes of PIN services by certified or trained auxiliary personnel per month.
- G0024 – Additional 30 minutes of PIN services by certified or trained auxiliary personnel per month.
- G0140 – Initial 60 minutes of PIN services by peer support specialist per month
- G0146 – Each additional 30 minutes of PIN services by peer support specialist per month
Who Can Bill for PIN
Physicians, NPPs (PAs, NPs, CNSs, CNMs), and Clinical Psychologists
Pro Tips
- Auxiliary personnel and peer support specialists do not necessarily require licensure to be eligible to provide services. Certification is likely required in most states.
- Valuable tool for combining patient education, collaboration, and care navigation for patients undergoing intense treatment regimens such as oncology care.
- Monthly billing provides predictable, recurring revenue.
- Digital health companies can support PIN services with technology and staff augmentation to streamline appointment scheduling and ongoing patient engagement.
- Useful way to address social determinants of health (SDOH) needs.
Community Health Integration (CHI)
Definition
Community Health Integration (CHI) services are designed to support patients with unmet social needs and chronic or acute conditions through non-clinical, community-based support. The goal is to reduce barriers to care, improve engagement, and connect patients to community-based services — especially for those impacted by social determinants of health.
Billing Codes
- G0019 – First 60 minutes of community health integration services by certified or trained auxiliary personnel.
- G0022 – Each additional 30 minutes by certified or trained auxiliary personnel per month.
Who Can Bill for CHI
Physicians or NPPs (NPs, PAs, CNMs, CNSs)
Pro Tips
- Designed for patients with unmet social needs (e.g., housing, food insecurity, transportation, etc.) that interfere with the management of an acute or chronic condition.
- Digital health companies can support providers offering CHI with simplified tools for assessing and documenting each patient’s social needs and identifying relevant community resources.
- Monthly billing offers predictable, recurring revenue.
Key Takeaways: Care Management Strategy for Digital Health Companies
Now that you have a basic understanding of the types of care management services most often utilized in healthcare innovation, you can start planning what’s next for your business. Here is some additional “food for thought” as you begin:
- Care management services are a gateway to value-based care. By enabling ongoing monitoring and patient communication, real-time data insight, and early intervention, you and your customers will be well-positioned to reduce the cost of care and improve patient outcomes in the long run.
- Each code set has specific billing requirements related to timekeeping, supervision, staffing, and documentation. The details matter and compliance is a competitive advantage.
- Digital health companies play a key role in care management services – reducing admin burden, augmenting care teams, providing valuable data analysis, and automating workflows are just a few of the ways in which you can have an impact.
- Many of the code sets described in this article are relatively new, which means they are evolving and subject to change. Keep an eye on annual updates from the American Medical Association and CMS so you are prepared for any changes that may impact your products or services.
We’re here to help
If you’re looking for ways to incorporate care management services into your current or future business model, contact us to see if we might be a good fit to help.