Care management is one of those terms everyone in health care uses and few define the same way. For a practice, the definition matters: it decides who does the work, what gets documented, and, for some Medicare patients, what can be billed.
This guide is for physicians, practice administrators and clinical staff in outpatient practices. It defines care management, explains how it differs from care coordination and case management, outlines the Medicare care management services published by the Centers for Medicare & Medicaid Services (CMS), and shows what care management looks like for a patient whose treatment spans several specialists over many months. For a side-by-side comparison of case and care management roles, see our guide on case management versus care management.
What is care management?
Care management is a team-based, patient-centered approach to helping patients and their support systems manage medical conditions more effectively. It includes the coordination activities needed to manage ongoing illness, such as assessing needs, building a care plan, following up and adjusting the plan as needs change.
That description comes from the Agency for Healthcare Research and Quality (AHRQ), which frames care management as an ongoing service, not a single task. In practice, care management usually means a named member of the care team keeps track of a patient between visits: whether they went to the referral, filled the prescription, understood the plan and are improving.
How is care management different from care coordination and case management?
Care coordination is the sharing of information and organizing of activities among everyone involved in a patient's care. Care management is a broader, ongoing service that uses coordination to help a patient manage their conditions. Case management is a collaborative process, often led by a professional case manager, of assessment, planning, coordination and advocacy for an individual's needs.
| Term | Core idea | Typical focus |
|---|---|---|
| Care coordination | Deliberately organizing care activities and sharing information among everyone involved in a patient's care (AHRQ) | The right information reaching the right people at the right time |
| Care management | A team-based, patient-centered approach to helping patients manage their conditions, including the coordination needed (AHRQ) | Ongoing support for patients with chronic or complex needs |
| Case management | A collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy (Case Management Society of America) | An individual's options and services, often across settings and payers |
The terms overlap, and organizations use them differently. AHRQ lists care management as one of the broad approaches to achieving coordinated care, alongside teamwork, medication management and health information technology. What matters for a practice is agreeing internally on who is responsible for each activity.
What care management services does Medicare pay for?
Medicare pays for several care management services under the Physician Fee Schedule, including chronic care management (CCM), principal care management (PCM), transitional care management (TCM) and chronic pain management. Each has its own eligibility rules, time thresholds and documentation requirements, described in the CMS Medicare Learning Network (MLN) booklet on chronic care management.
- Chronic care management. For patients with two or more chronic conditions expected to last at least 12 months, or until death, that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. Codes are based on time per calendar month and who does the work: CPT (Current Procedural Terminology) 99490 and add-on 99439 for clinical staff time, 99491 and add-on 99437 for time spent personally by the physician or other qualified professional, and 99487 and add-on 99489 for complex CCM.
- Principal care management. For a single high-risk chronic condition expected to last at least 3 months. Codes 99424 through 99427.
- Chronic pain management. A monthly bundle that includes assessment, a validated pain rating scale, a person-centered care plan, medication management and coordination with other practitioners such as physical therapy. HCPCS (Healthcare Common Procedure Coding System) codes G3002 and add-on G3003, with an initial face-to-face visit of at least 30 minutes.
- Transitional care management. Covers the 30-day period after discharge from an inpatient setting. Codes 99495 and 99496.
The booklet also sets common requirements for CCM: an initiating visit for new patients or those not seen in the past year, documented patient consent, a comprehensive electronic care plan, 24/7 access to care, and recording patient information in certified EHR (electronic health record) technology. It notes that only one practitioner can bill CCM for a patient in a calendar month. Rules change each year with the Physician Fee Schedule, so check the current CMS guidance before billing.
What does a care plan include?
A care plan lists the patient's problems, measurable goals, planned interventions, who is responsible for each step, and when the plan will be reviewed. CMS describes a comprehensive care plan that can include a problem list, expected outcomes, measurable treatment goals, symptom management, planned interventions, coordination with outside practitioners and periodic review.
Even when a practice is not billing a care management code, these elements make a plan usable. A plan without owners and review dates tends to be written once and never opened again.
