You already do the work. The fifteen minutes on the phone with the pharmacy. The note you sent the BCBA so the home program matched the clinic plan. The med list you updated after the cardiology visit, the consent you tracked down, the care plan you revised because the family's situation changed. None of it happened in a billable encounter, so none of it showed up on a claim. It just disappeared into the part of the week that no one pays for.
For a lot of clinicians and care organizations, that uncompensated coordination is the job — and it's also the single largest pool of reimbursement they never touch. Medicare and most commercial payers have, for years, paid for exactly this kind of between-visit work. The codes exist. The rates are real. The reason most small practices leave the money on the table isn't that they don't qualify — it's that capturing the time defensibly is genuinely hard. This guide walks through what care-coordination billing actually is, the main code families in 2026, what a realistic month looks like, and why the capture problem is the whole ballgame.
The coordination isn't extra work you'd have to add. It's work you're already doing — just not getting paid for.
What is care-coordination billing?
Most of medicine is billed by the encounter — a visit, a procedure, a session. Care-coordination billing is different. It pays for clinical time spent between visits managing a person's care: reviewing records, talking to other providers, adjusting medications, updating the care plan, coordinating with family and community resources, and checking in on how the plan is actually going.
It exists because the sickest, most complex people aren't kept well by the visit itself. They're kept well by everything that happens in the weeks between visits — and someone has to do that work. The Medicare programs below are the formal mechanism for paying for it. They share a common spine:
- A qualifying condition or situation (chronic conditions, a behavioral health diagnosis, a recent discharge).
- A care plan that's documented, shared, and revisited.
- Patient consent, captured before billing begins.
- A monthly time threshold of clinical-staff or practitioner time you have to meet and document to bill.
That last point is where it all lives or dies. These are time-based codes. If you can't show the minutes, you can't bill them — no matter how much coordinating you actually did.
Chronic Care Management (CCM): the workhorse
Chronic Care Management is the most widely used care-coordination program, and the best place for most practices to start.
Who qualifies
A patient with two or more chronic conditions expected to last at least 12 months (or until death) that place them at significant risk. Think diabetes plus hypertension, or a developmental disability plus a seizure disorder plus a behavioral health diagnosis. You also need a comprehensive, shared care plan, 24/7 access to a care team member for urgent needs, and documented patient consent.
The codes and what they pay (CY2026)
- CPT 99490 — the base code. 20 minutes of clinical-staff time per calendar month, directed by the billing practitioner. National-average Medicare reimbursement is roughly $62.
- CPT 99439 — the add-on. Each additional 20 minutes in the same month, roughly $47 each, billable up to two times.
So a month where your staff spends a full hour coordinating one complex patient's care can bill 99490 plus two units of 99439 — the base 20 minutes plus two more 20-minute blocks.
The key mental shift: 99490 isn't paying you to do something new. It's paying for the medication reconciliation, the specialist coordination, and the care-plan updates you're already doing — once you can prove the 20 minutes.
Principal Care Management (PCM): one condition, high complexity
Not every complex patient has two qualifying conditions. Principal Care Management covers the person with a single, serious chronic condition — one that's complex enough to need its own dedicated management, often after a hospitalization or during an acute phase of a long-term illness.
PCM uses its own code set:
- 99424 / 99425 — practitioner-provided care management time.
- 99426 / 99427 — clinical-staff time directed by the practitioner.
It's the right tool when one condition is doing all the work, and CCM's two-condition requirement doesn't fit.
Behavioral Health Integration (BHI): coordinating mental health care
Behavioral Health Integration pays for managing a patient's behavioral health needs inside a primary or specialty practice — the coordination, follow-up, and care-plan revision around a mental health or substance use condition.
- CPT 99484 — 20 minutes of clinical-staff time per calendar month spent on behavioral health care management.
The defining requirement: BHI is measurement-based. You have to capture a validated rating scale (a PHQ-9, a GAD-7, or another validated instrument) that month and use it to inform care. No scale on file for the month, no BHI claim. For practices already screening, that's a small step; for practices that screen informally, it's the gap to close first.
Collaborative Care (CoCM): the team-based behavioral health model
Collaborative Care is BHI's more structured, higher-intensity sibling — a specific, evidence-based model with a treating practitioner, a behavioral health care manager, and a psychiatric consultant working as a team.
These codes are active in 2026 — they have not been retired:
- CPT 99492 — initial month, 70 minutes of care-manager time.
- CPT 99493 — subsequent months, 60 minutes.
- CPT 99494 — an add-on for each additional 30 minutes in a given month.
CoCM has real infrastructure requirements: a patient registry to track the whole caseload, weekly caseload review with the psychiatric consultant, and monthly measurement-based care so treatment changes when someone isn't improving. It pays more because it asks more — but for practices building genuine integrated behavioral health, it's the model the payment system was designed around.
Transitional Care Management (TCM): the period after a discharge
Transitional Care Management is encounter-based rather than purely time-based, but it belongs in any coordination conversation because the days after a hospital or facility discharge are when coordination matters most.
- 99495 / 99496 — covering the 30 days following discharge, including a timely interactive contact, medication reconciliation, and a face-to-face visit within the required window.
TCM is how you get paid for catching the person in the fragile window where readmissions happen — the calls, the med reconciliation, the follow-up that keeps a discharge from bouncing back.
How much can a small practice realistically capture?
Run the simplest, most conservative math — CCM at the base code only, no add-ons:
- One eligible patient, one 20-minute block of coordination a month: 99490 ≈ $62.
- Fifteen eligible patients managed at that base level: 15 × $62 ≈ $930 per month, or roughly $11,000 a year.
And that's the floor. It ignores 99439 add-on time for your more complex patients, ignores BHI and CoCM entirely, and assumes only fifteen people. A panel with real complexity — Medicare, dual-eligible, or complex-care clients, exactly the population a BCBA, OT, SLP, counselor, or care coordinator tends to serve — has far more than fifteen people who'd qualify, and many of them generate more than the base 20 minutes a month.
The point isn't the exact figure. It's that this is a meaningful, recurring revenue line built entirely from work you're already doing — and for most small practices, it's currently $0.
Why most practices leave this on the table
If the work is already happening and the codes already exist, why is so much of this revenue uncaptured? One reason, almost every time: capturing the time defensibly is hard.
- The minutes are scattered. Two minutes here, eight minutes there, across phone calls, messages, chart updates, and hallway conversations — spread over a whole month and several people. Nobody's holding a stopwatch.
- Reconstruction doesn't hold up. Trying to remember at month-end how many minutes you spent on someone three weeks ago isn't documentation — it's a guess, and it's exactly what an audit is built to find.
- The threshold is invisible until it's missed. You can't tell mid-month whether a patient has crossed 20 minutes, so you either under-bill the ones who qualified or chase minutes you can't substantiate.
- The output is a chore. Even when the time exists, turning it into a clean, chart-ready superbill with the right codes, dates, and attribution is manual work most small teams never get to.
So the time evaporates, the threshold gets missed, and the claim never goes out. Not because the practice didn't earn it — because nothing was capturing it as it happened.
How Trellis makes it billable
This is the exact problem Trellis is built to solve. The coordination work already flows through the platform — the notes, the messages, the care-plan updates, the cross-team handoffs. Trellis turns that activity into defensible, billable time without adding a second job on top of the first:
- A coordination time-ledger. Coordination time is captured as it happens, attributed to the right person and the right patient, instead of reconstructed from memory at month-end. Real minutes, logged at the moment of the work.
- Live threshold tracking. Trellis knows when a patient crosses 20 minutes for CCM or BHI, or hits a CoCM block — so you can see who's billable this month while there's still time to act, not after the window closes.
- Consent and enrollment tracking. The consent and program-enrollment requirements that gate these codes are tracked alongside the time, so you're not billing without the paperwork that has to come first.
- A chart-ready superbill. A monthly rollup assembles the documented time into a clean superbill with the right codes, dates, minutes, and supervising-provider attribution — the artifact your biller actually needs.
- FHIR export. When the documentation needs to live in or move to an EHR, Trellis can export it in a standards-based format rather than trapping it in another silo.
You can see how Trellis handles all of this on the provider page — and estimate your own numbers with the ROI calculator there, using your real panel size and complexity. When you're ready to compare plans, the pricing page lays out the tiers.
A note on scope, and a disclaimer
This article is general information, not billing, coding, or legal advice. Reimbursement rules, covered codes, required documentation, and payment rates vary by region, payer, and year, and they change. The dollar figures here are approximate national-average Medicare values for CY2026 and will differ from what any specific payer pays you. Before you bill any of these codes, confirm the current requirements with the relevant payer and, where appropriate, a qualified billing or compliance professional. Trellis helps you capture and document coordination time defensibly; it does not determine your eligibility, set your rates, or submit your claims.
The work is real. The codes are real. The only thing missing, for most practices, is a way to capture the time as it happens — so the coordination you're already doing finally shows up where it should.
See how Trellis turns coordination into a chart-ready superbill →