Value-Based Care Glossary

This value-based care glossary will give you any definitions you need to know about chronic care management, annual wellness visits, or MIPS.

Chronic Care Management (CCM)

Chronic care management includes the oversight and educational activities conducted by health care professionals to help patients with chronic diseases and health conditions such as diabetes, high blood pressure, lupus, multiple sclerosis, and sleep apnea. CCM helps patients understand their conditions and how to live successfully with them. The work involves motivating patients to engage in necessary actions to achieve an ongoing, reasonable quality of life.

On January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) implemented a new reimbursement program for providers administering chronic care management (CCM) services. The program is designed to reimburse an average of $42 per month for each patient enrolled in a chronic care management program under a specific set of circumstances. Ultimately, the goal is to increase access to primary care services for chronically ill patients, improve patient outcomes, and help lower the financial strain on the healthcare system.

CCM Patient Eligibility

  • Two or more chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • A qualifying office visit within the previous 365 days
  • Only one provider billing for CCM services
  • Verbal or written consent from the patient

CCM Service Elements

  • Minimum of 20 minutes per month of non-face-to-face care
  • 24/7 access to care management
  • Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff
  • Ensure continuity of care with a member of the care team with whom the patient is able to schedule successive routine appointments
  • Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other non-face-to-face consultation methods (for example, email or secure electronic patient portal)
  • A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements
    • Problem list
    • Expected outcome and prognosis
    • Measurable treatment goals
    • Symptom management
    • Planned interventions and identification of the individuals responsible for each intervention
    • Medication reviews
    • Community/social services ordered
    • A description of how the services of agencies and specialists outside the practice will be directed/coordinated
    • Schedule for periodic review and, when applicable, revision of the care plan

MIPS (Merit-based Incentive Payment System)

4 Components

  • Quality (formerly known as Physician Quality Reporting System (PQRS))
  • Cost ( formerly known as Value-Based Payment Modifier (VM))
  • Promoting Interoperability (formerly known as Medicare EHR Incentive Program EHR for eligible professionals)
  • Improvement Activities


  • Move Medicare Part B clinicians to a value-based payment system
  • Provides clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
  • Reporting standards align with Advanced APMs wherever possible


CMS (Centers for Medicare and Medicaid Services)

The Centers for Medicare & Medicaid Services (CMS) is part of the U.S. Department of Health and Human Services. CMS oversees many federal healthcare programs, including those that involve health information technology such as the meaningful use incentive program for electronic health records (EHR).

Non-Face-to-Face Chronic Care Management

Care managers can use the telephone, or other non-face-to-face means to contact and monitor patients regularly. Support is also offered to deliver patient education and counseling, give appointment reminders, and facilitate peer support and referrals for coping with illness.

Chronic Care Management Software/Platform

Software used to manage the care of chronically ill patients.

Chronic Care Coordinator

Medicare patients with two or more chronic conditions are offered twenty minutes of care monthly through a Chronic Care Coordinators. They collaborate with primary care physicians, specialists, and hospitals to create a comprehensive, individualized care plan around the patient’s needs.

CCM Billing Codes

CCM uses five primary codes to report services:

99490 non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.

99491 CCM services provided personally by a physician or other qualified health care professional for 30 minutes.

99487 60 minutes of complex CCM which includes some medical decision making.

99489 add on code for an additional 30 minutes of complex CCM billed in conjunction with 99487

G0511 HCPCS code for CCM used by rural health clinics (RHCs) and federally qualified health centers (FQHCs)

CCM Certification

CCM certification is recognized as the gold standard for case manager excellence, across all health care and health management settings.

Annual Wellness Visit (AWV)

The AWV is an ongoing yearly benefit starting after 12 months of enrollment in Part B Medicare coverage. The AWV is designed to provide clinical preventive services across all three stages of disease development: 1) before disease occurs, 2) before disease is clinically evident, and 3) before established disease has made its maximal impact. The information from the AWV is used to develop or update a plan to prevent disease and disability based on the beneficiary’s current health status and risk factors.

FQHC (Federal Qualified Health Center)

A Federally Qualified Health Center is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. It is a community-based organization the provides comprehensive primary care and preventative care for qualifying patients.

CMMI (Center for Medicare and Medicaid Innovation)

An area within CMS committed to testing innovative payment techniques and service delivery models to improve quality of care.

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