Can Outside Staff Deliver CCM Under Incident To Rules?

Updated October 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

Yes, outside clinical staff can deliver the staff portion of Chronic Care Management (CCM), but only if Medicare's incident to rules are met. CMS's CCM FAQs, last updated in August 2022, say a billing practitioner may arrange for external clinical staff, such as a case management company, as long as the practitioner stays involved and the team is clinically integrated with the practice.

Key facts

• Who can be clinical staff: CMS says CCM clinical staff are employees or people working under contract with the billing practitioner (MLN booklet).
• Supervision level: CCM codes 99487, 99489, 99490 and 99439 are assigned general supervision under the Physician Fee Schedule, so the practitioner doesn't need to be in the room.
• External companies: the CMS CCM FAQs (last updated 16 August 2022) allow external clinical staff if all incident to rules are met.
• Not delegable: the billing practitioner's oversight, management, collaboration and reassessment work can't be subcontracted. Neither can the medical decision making in complex CCM (99487, 99489).
• Outside the United States: CCM can't be billed if staff or patients are located outside the country, because of 42 CFR 411.9.
• 99491 and 99437: these codes are for time the billing practitioner personally spends, so they can't be furnished incident to.
• Pending rule: the CY2027 proposal would require RPM and RTM clinical staff to be direct employees from 1 January 2027 if finalized. That proposal is about remote monitoring, not CCM.

Can an outside company deliver the clinical staff portion of CCM?

Yes, with conditions. The CMS FAQ asks directly whether the clinical staff portion of CCM can be performed by external third party companies. The answer is that a billing practitioner may arrange it if all the incident to and other billing rules are met.

The warning comes in the next sentence. If there is little oversight by the billing practitioner, or a lack of clinical integration between the third party and the practitioner, CMS doesn't believe CCM could actually be furnished. In that case the practitioner shouldn't bill.

So the question isn't really "inside or outside." It's whether the care team calling your patient works as part of your practice, under your direction, using your care plan. An outside nurse who reads your chart, follows your plan and escalates to you can qualify. A call center that never touches your records can't.

What does "incident to" mean for CCM?

Incident to is the Medicare rule that lets a practitioner bill for services furnished by auxiliary personnel as part of the practitioner's own service. The rule lives at 42 CFR 410.26.

That regulation defines auxiliary personnel as any individual acting under the supervision of the practitioner, regardless of whether the person is an employee, leased employee or independent contractor. The person must not be excluded from federal health care programs. They must also meet state licensure requirements for the services they provide.

Two details matter here. Only the supervising practitioner may bill Medicare for incident to services. And the supervising practitioner doesn't have to be the one who treats the patient more broadly.

This is why CMS describes CCM staff as employees or people under contract. The contract is with the billing practitioner, and the billing practitioner stays accountable for the service.

What level of supervision does CCM require?

General supervision. Under 410.26, general supervision means the service is furnished under the practitioner's overall direction and control, but the practitioner's presence isn't required while the service is performed. The same section says designated care management services can be furnished under general supervision.

For you, that means a nurse can make calls from another building or another city, as long as she works under your direction and within her state scope of practice. Nobody has to stand next to her.

General supervision doesn't mean hands off. The practice still trains the staff, sets the care plan, reviews escalations and owns the documentation. Think of it as direction without presence.

Which parts of CCM can't be handed to an outside team?

Three things stay with the billing practitioner. CMS says the CCM codes are valued to include ongoing practitioner work: oversight, management, collaboration and reassessment. That work "cannot be delegated or subcontracted to any other individual."

• Practitioner oversight: you review the care plan, respond to escalations and stay involved each month.
• Complex CCM decision making: codes 99487 and 99489 include moderate to high complexity medical decision making by the billing practitioner during the service period.
• Personally performed time: 99491 and 99437 count only time the practitioner personally spends, so staff time can't be used for them.

Two more rules sit around the delivery model. The initiating visit and patient consent are separate requirements, and both belong to the billing practitioner. Also, only one practitioner can bill CCM for a patient in a calendar month. Your arrangement has to make sure only one practitioner bills for each patient.

For the details on consent and care plans, see our guide to CCM consent and care plan requirements. For which code fits which time threshold, see the CCM billing codes guide.

How much oversight is enough when staff are external?

CMS hasn't published a number. The FAQ uses the phrases "little oversight" and "lack of clinical integration," and it doesn't define either. That's the honest limit, and it's why auditors read your documentation closely.

Here's a practical checklist of what a reviewer would want to see:

1. A written agreement that names the billing practitioner as the supervising practitioner.
2. Evidence the external staff hold the licenses or credentials the services require in the state where they work.
3. Access to your EHR or a shared record, so the care plan lives in one place.
4. A defined escalation path, with a named person at the practice who answers.
5. Monthly practitioner review, documented, of the patients and the care plan.
6. Time logs that show who did what, for how long, on which date.
7. Confirmation that no staff or patient is outside the United States during the service.

If you can't produce items like these, treat that as a signal to tighten the arrangement before you bill. A practice that outsources the work and then can't show its own involvement is the case CMS describes.

Does the CY2027 proposal change this for CCM?

Not as proposed, and the proposal is about different codes. On 16 July 2026 CMS published the CY2027 Physician Fee Schedule proposed rule. In its fact sheet, CMS proposes to allow payment for remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) only when performed by clinical staff employed by the practice, not by contractors.

That would end the outsourced model for RPM and RTM if finalized. The fact sheet doesn't propose the same limit for CCM. CCM still follows the FAQ and the incident to regulation described above.

The proposal is also contested. Senators Warner and Blackburn wrote to CMS on 23 September 2026 asking it not to finalize the restrictions as proposed. The final rule is expected later this fall, so check the final text before you change anything. We cover the RPM side in our CY2027 RPM and RTM explainer.

One caution. Rules can drift over time, and CMS could look at CCM staffing in a later rulemaking. Build your arrangement as if oversight will be audited, because it can be today.

What this means for your practice

If you use or are considering outside clinical staff for CCM, do four things this month.

• Read the agreement and confirm it names your practitioner as supervising and billing.
• Pull a sample of monthly records and check that your own review is documented.
• Confirm that no outside partner bills CCM for your patients under a different NPI.
• Ask your MAC or compliance counsel how they read "clinical integration" for your setup.

HANA Health builds care management outreach tools for practices, and you can see how that fits alongside your own team at HANA Remote. Billable time still has to come from clinical staff working under your supervision.

Frequently asked questions

Can a nurse who works from home deliver CCM for my practice?

Yes. General supervision doesn't require the practitioner's presence, and CMS doesn't require staff to sit in your office. The nurse still has to meet state licensure and scope rules, work under your direction and document her time.

Do independent contractors count as clinical staff for CCM?

Under 42 CFR 410.26, auxiliary personnel can be employees, leased employees or independent contractors. CMS's CCM booklet describes clinical staff as employees or people working under contract with the billing practitioner.

Can the outside company bill Medicare for CCM itself?

Not under this model. Only the supervising practitioner may bill Medicare for incident to services. The outside company is paid by you under your contract, not by Medicare.

Can staff in another country make CCM calls?

No. CMS says CCM can't be billed when services are furnished by individuals outside the United States, or to beneficiaries outside the United States.

Does the RPM contractor proposal apply to CCM?

As proposed, it applies to RPM and RTM only. CCM isn't named in the CMS fact sheet's employee requirement. Watch the final rule for any change.

Sources

1. CMS, Chronic Care Management Frequently Asked Questions, last updated 16 August 2022.
2. CMS Medicare Learning Network, MLN909188, Chronic Care Management Services.
3. eCFR, 42 CFR 410.26, Services and supplies incident to a physician's professional services.
4. CMS, Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule fact sheet, July 2026.
5. Federal Register, CY 2027 Payment Policies Under the Physician Fee Schedule, CMS-1848-P, 16 July 2026.
6. Senator Mark Warner, Warner, Blackburn urge CMS to reconsider proposed restrictions on remote patient monitoring, 23 September 2026.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. If you want to talk through how your CCM staffing is set up, book a discovery call.