Medicare care-management programs, explained
What each program is, who qualifies, and what it takes to bill it compliantly.
Chronic Care Management
A monthly non-face-to-face service for patients with two or more chronic conditions, covering care planning, 24/7 access, and coordination between visits.
Codes: 99490, 99439, 99491, 99437, 99487, 99489, G0506
View programBehavioral Health Integration
Monthly codes for integrating behavioral health care into a primary care or specialty practice, from a general model to the structured Psychiatric Collaborative Care Model (CoCM).
Codes: 99484, G0323, 99492, 99493, 99494, G2214, G0568, G0569, G0570
View programCommunity Health Integration
A monthly service for connecting patients to community-based resources that address unmet social needs, such as housing, food, or transportation, that are interfering with an existing medical treatment plan.
Codes: G0019, G0022
View programPrincipal Care Management
A monthly care-management service for a single, high-risk chronic condition, aimed at specialists and generalists managing one complex problem rather than a whole patient panel.
Codes: 99424, 99425, 99426, 99427
View programChronic Pain Management
A monthly bundled service for patients with chronic pain lasting longer than 3 months, covering a person-centered care plan, medication management, and coordination with behavioral health and rehab providers.
Codes: G3002, G3003
View programRemote Physiologic Monitoring
Codes for supplying a connected device that captures physiologic data (like blood pressure or weight) and for the clinical staff time spent reviewing and acting on it each month.
Codes: 99453, 99454, 99445, 99457, 99458, 99470
View programRemote Therapeutic Monitoring
Codes for monitoring musculoskeletal, respiratory, or cognitive behavioral therapy adherence and response, using patient-reported or device-captured non-physiologic data.
Codes: 98975, 98976, 98977, 98978, 98984, 98985, 98986, 98980, 98981, 98979
View programAnnual Wellness Visit
A yearly, conversation-based preventive visit to build or update a personalized prevention plan, distinct from a routine physical exam, plus an optional same-day advance care planning discussion.
Codes: G0438, G0439, 99497, 99498
View programAdvanced Primary Care Management
A flat, three-tier monthly service introduced in CY2025 that bundles the care-management work of CCM, PCM, and TCM into one code, with no minutes to track.
Codes: G0556, G0557, G0558
View programTransitional Care Management
A 30-day bundled service for the first outpatient contact and follow-up visit after a patient is discharged from an inpatient or institutional setting back to the community.
Codes: 99495, 99496
View program