Medicare has no official list of diagnoses that qualify a patient for chronic care management. Which conditions qualify for chronic care management is decided by a two-part test, not a lookup table: the patient must have two or more chronic conditions expected to last at least 12 months or until death, and those conditions must place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. CMS names fourteen example conditions in its own booklet and says plainly that the list is not exhaustive. Almost any combination that meets the duration and risk test counts.
That single design decision is why practices get stuck. Staff go looking for the qualifying list, cannot find one, and either enroll too conservatively or enroll patients whose charts will not support the risk half of the test. This guide walks the criteria that decide which conditions qualify for chronic care management, the conditions CMS names, the boundary cases that belong in a different program, and the rules that disqualify an otherwise eligible patient in a given month.
On this page
- Which conditions qualify for chronic care management: the two-part test
- The fourteen conditions CMS names as examples
- A wrinkle in the CMS booklet worth knowing before an audit
- Conditions that qualify a patient for a different program
- Complex CCM needs one thing more than the condition test
- What disqualifies an otherwise eligible patient this month
- How to screen a panel without guessing
- What building a program of our own taught us about eligibility
- What these codes pay in 2026
- Frequently asked questions
- Where to take this next
- Sources
Which conditions qualify for chronic care management: the two-part test
The criteria live in the CMS booklet Chronic Care Management Services (MLN909188, June 2025). Two things have to be true at once.
Part one, duration. The patient has multiple chronic conditions, defined as two or more, expected to last at least 12 months or until the patient’s death. A condition that will resolve in a few months does not count toward the pair, however serious it is while it lasts.
Part two, risk. Those conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. This is the half that practices skip, and it is the half that is a clinical judgment rather than a data query. It has to be visible in the record.
Notice that neither half of the test names a diagnosis. Which conditions qualify for chronic care management is therefore a question about duration and risk, not about disease category. CMS suggests identifying candidates using criteria from CPT guidance, such as the number of illnesses, the number of medications, or repeat admissions and emergency department visits. In other words, the agency expects you to build a screen, not to check names against a roster.
The fourteen conditions CMS names as examples
The booklet does give a list, and it is worth reading carefully, because it is introduced with the words “include but aren’t limited to.” These are illustrations of conditions that commonly meet the test, not a definition of eligibility.
- Alzheimer’s disease and related dementia
- Arthritis, both osteoarthritis and rheumatoid arthritis
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer
- Cardiovascular disease
- Chronic obstructive pulmonary disease
- Depression
- Diabetes
- Glaucoma
- HIV and AIDS
- Hypertension
- Substance use disorders
In a general primary care panel the qualifying pairs repeat endlessly: diabetes with hypertension, heart failure with chronic kidney disease, COPD with depression. In a specialty panel they look different but appear just as often. A patient with osteoarthritis and atrial fibrillation who is losing function meets the test as squarely as a patient with the classic cardiometabolic pair.
What matters is that a condition absent from those fourteen is not excluded. Chronic kidney disease, heart failure, obesity, and osteoporosis are nowhere in the CMS examples, and all of them routinely qualify when the duration and risk criteria are met and documented.
A wrinkle in the CMS booklet worth knowing before an audit
Here is something you will not find in most summaries of this topic, and we only caught it by reading the source document rather than someone’s recap of it.
On page 5, the eligibility paragraph joins the two parts with the word “or”: conditions “expected to last at least 12 months or until the patient’s death or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.” Read literally, that would let a patient qualify on the risk test alone.
On page 9, the same booklet sets out Table 1, headed Required Elements, and lists the duration criterion and the risk criterion as two separate rows, each checked for both chronic care management and complex chronic care management. Read that way, both are required.
The tables are the operative statement of the required elements, and every version of the CPT language treats the two as conjunctive. The safe position, and the one we use, is to document both: the expected duration of each condition and the specific risk the combination creates for that patient. It costs one extra sentence in the care plan and it removes the only reading of the booklet under which your documentation would fall short. If a reviewer ever applies the stricter interpretation, charts written the loose way have nothing to point at.
Conditions that qualify a patient for a different program
A patient who fails the CCM test is not necessarily a patient with no care management option. Three of the boundaries come up constantly.
| Patient situation | Program that fits | Codes |
|---|---|---|
| Two or more chronic conditions, 12 months or until death, with significant risk | Chronic care management | 99490, 99439, 99491, 99437 |
| The same patient, plus moderate or high complexity medical decision making | Complex chronic care management | 99487, 99489 |
| One single high-risk chronic condition expected to last at least 3 months | Principal care management | 99424 through 99427 |
| Primary care relationship, billed monthly with no minute counting | Advanced primary care management | G0556, G0557, G0558 |
The single-condition case is the one that trips practices up most. A patient with one serious, high-risk condition expected to last at least three months, placing them at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death, is not a patient whose conditions qualify for chronic care management. They may well qualify for principal care management instead, which carries a 30-minute monthly minimum and requires another initial visit after a year. The detail sits in our guide to the PCM codes 99424 through 99427.
Advanced primary care management works differently again, and the condition count drives the level rather than eligibility itself. G0556 covers patients with one or fewer chronic conditions, G0557 covers patients with two or more, and G0558 covers patients with two or more who also hold Qualified Medicare Beneficiary status. Because APCM is a monthly bundle with no time threshold, the arithmetic of choosing between it and CCM is genuinely different, and we walk it in the guide to the APCM codes G0556, G0557 and G0558.
Complex CCM needs one thing more than the condition test
Complex chronic care management uses the identical patient eligibility criteria. The difference is not the diagnoses. Complex CCM requires moderate or high complexity medical decision making by the physician or other billing practitioner, on top of the longer time threshold. A patient does not become a complex CCM patient because their condition list is long. They become one because the decisions their care requires that month were genuinely complex, and the record shows it. The requirements are broken out in our guide to complex CCM codes 99487 and 99489.
What disqualifies an otherwise eligible patient this month
Eligibility is not only about the patient. A patient who passes the condition test can still be unbillable in a given calendar month because of what else is being billed. The booklet’s concurrent billing rules are specific.
- You cannot report non-complex and complex CCM for the same patient in the same calendar month.
- You cannot bill CCM during the same service period as home health care supervision (G0181), hospice care supervision (G0182), or certain ESRD services (90951 through 90970).
- You can bill either remote physiologic monitoring or remote therapeutic monitoring concurrently with CCM, but not both.
- Only one practitioner may provide and bill CCM for a patient in a calendar month, which is one of the facts you must disclose when obtaining consent.
- Time counted toward CCM cannot be counted toward any other billed code.
One rule runs the other way and is worth knowing because practices often assume the opposite: CCM codes 99487, 99489, 99490 and 99491 can be reported for services provided during the 30-day transitional care management period. A recent discharge does not put the patient out of reach.
Two administrative gates sit alongside the clinical ones. New patients, and patients you have not seen within the previous year, need an initiating visit before services start, conducted during a face-to-face evaluation and management visit, an annual wellness visit, or an initial preventive physical exam. And consent, written or verbal, must be obtained and documented before you bill, covering the availability of the service, the patient’s cost sharing, the single-practitioner rule, and their right to stop at the end of any month.
How to screen a panel without guessing
The practical screen has three steps, and only the first is a database query.
Start by pulling every patient with two or more chronic problems on the active problem list who has been seen in the past twelve months. That gives you a candidate pool, not an enrollment list, because the query can only answer half of which conditions qualify for chronic care management. Then sort that pool by how much uncompensated coordination your staff already performs: the patients who generate the most phone calls, refill juggling, specialist chasing and post-discharge follow-up are the ones where the risk half of the test is already true and already documented in your own messages. Those patients are your first cohort. Finally, have the billing practitioner confirm and record the risk judgment for each one, in the care plan, in plain clinical language.
That last step is the one that gets skipped under time pressure, and it is the only step a reviewer can actually check.
What building a program of our own taught us about eligibility
Our team designed, implemented and supports an in-house care management program at our clinic, a musculoskeletal and regenerative medicine practice. The clinic’s own staff run it day to day. It is a remote therapeutic monitoring and principal care management program rather than a CCM program, which is exactly why the eligibility boundary became the interesting problem for us rather than an abstract one.
The lesson that transferred to every practice we have advised since: the hard eligibility question is almost never “does this diagnosis count.” It is “is this a two-condition patient or a one-condition patient.” Panels are full of people carrying one dominant, genuinely high-risk problem plus a couple of stable, low-consequence entries on the problem list. Counting problem-list rows makes them look like chronic care management patients. Reading the chart makes them look like principal care management patients. Getting that call wrong does not usually produce a denial, which is what makes it dangerous. It produces a chart that will not survive a look.
The second lesson is that the coinsurance conversation, not the criteria, is where enrollment actually stalls. Patients who qualify cleanly still decline when the cost sharing is explained badly. That is a script problem, and it is worth solving before you scale enrollment rather than after.
What these codes pay in 2026
Eligibility only matters if the economics work, so here are the national amounts for the codes above. These are 2026 national non-facility amounts and are not adjusted for your locality.
| Code | Service | 2026 national non-facility |
|---|---|---|
| 99490 | CCM, first 20 minutes of clinical staff time | $66.13 |
| 99439 | CCM, each additional 20 minutes | $50.44 |
| 99487 | Complex CCM, 60 minutes | $144.29 |
| 99491 | CCM by physician or other qualified professional, 30 minutes | $89.18 |
| 99424 | PCM by physician or other qualified professional, 30 minutes | $87.51 |
To see what an eligible cohort is actually worth against your own panel size and staffing, our in-house versus vendor revenue calculator does the arithmetic, and the CPT 99490 guide covers the monthly service requirements that sit behind the first code in that table.
Frequently asked questions
Does CMS publish a list of which conditions qualify for chronic care management?
No. CMS names fourteen example conditions in MLN909188 and introduces them with “include but aren’t limited to.” Eligibility turns on the duration and risk test, not on membership in a list, so a condition that does not appear among the examples can still qualify.
Do both chronic conditions have to be actively treated by our practice?
The criteria do not require that. They require that the patient has the conditions, that they meet the duration test, and that they create significant risk. What your practice must do is provide the comprehensive care management the codes describe, which means the care plan has to address the whole picture rather than only the problems in your specialty.
Can a patient with only one chronic condition ever qualify?
Not for chronic care management. One single high-risk chronic condition expected to last at least three months points to principal care management instead, which has its own codes, its own 30-minute monthly minimum, and its own annual initial-visit requirement.
Can two practices bill chronic care management for the same patient in the same month?
No. Only one practitioner may provide and bill CCM for a patient in a calendar month, and telling the patient so is a required part of the consent conversation.
Does the proposed 2027 staffing rule change who qualifies?
No. The staffing provision in the CY 2027 Physician Fee Schedule proposed rule addresses who may furnish remote physiologic monitoring and remote therapeutic monitoring services. It is a proposed rule, it does not alter patient eligibility for chronic care management or principal care management, and no part of it restricts outsourced CCM. We track it in our explainer on the proposed RPM and RTM staffing requirement.
Where to take this next
Deciding which conditions qualify for chronic care management is the first gate, not the whole build. If you are deciding whether to build a program at all, the broader picture sits in our guide to what chronic care management is, and the build-versus-buy question is worked through in our comparison of chronic care management companies and in-house programs. Our full approach to care management program design and implementation explains how we help practices stand these programs up, with the practice’s own staff running them.
If you want a second read on whether your panel supports a program, get in touch and we will walk through the eligibility math with you.
Sources
- CMS, Chronic Care Management Services, MLN909188, June 2025. Patient eligibility p.5, initiating visit p.5, consent p.6, medical decision making p.7, concurrent billing p.8, required elements Table 1 p.9, APCM and PCM p.11.
- CMS Physician Fee Schedule Relative Value File RVU26C, July 2026 release. National non-facility amounts computed at the 2026 conversion factor, not adjusted for locality.
