A Medicare-backed program that supports long-term management of chronic conditions through monthly care coordination.

Understanding CCM: A Preventive Approach to Chronic Conditions

Getting ahead of your chronic condition starts here. We are here to answer, What is Chronic Care Management?

The Chronic Care Management (CCM) initiative was launched by the Centers for Medicaid Services in 2015. Curated to enhance care for patients with certain chronic conditions, CCM empowers providers to offer consistent, coordinated support outside office visits.

CCM focuses on preventing early adaptation and monitors continuously. It does not just treat illnesses when the symptoms worsen. This long-term strategy is not only beneficial for patient health results but also diminishes hospitalizations and emergency room visits.

At RPM & CCM Health, we help practices implement this vital program seamlessly, enhancing patient care while unlocking monthly reimbursements. For providers, it proves to be the most sustainable way to improve results while receiving monthly reimbursements via Medicare’s CCM program.

What patients get:

• Fewer hospitalizations and emergency visits.
• Personalized care and education.
• Stronger connections with care teams.

What providers get:

• Monthly Medicare reimbursement
• Improved care coordination
• Stronger patient relationships

The Main Goals of CCM

Our Chronic Care Management program is designated in preventive medicine. Its baseline encourages long-term health improvements such as:

Enhances communication: Staying in contact with a caretaker brings trust and provides patients with timely answers to their queries and questions.

Stronger care continuity: Patients tend to engage with their treatment plans between visits, which improves long-term results.

Better Treatment: Ongoing guidance allows patients to follow their medication regimens and recommend therapies accordingly.

Few emergency visits: By addressing symptoms and coordinating care, CCM significantly reduces hospital visits.

Supporting patients: With better information on their conditions, patients feel more in charge of their own health decisions.

Who Is Eligible for CCM? (Clinical Criteria For CCM)

At RPM & CCM Health, we understand the importance of clarity when it comes to eligibility. To participate in Chronic Care Management, patients must meet specific Medicare-defined criteria.

They certainly have two or more chronic conditions that are:

• Expected to last at least 12 months, or until the patient dies.
• Likely to put them at risk of death or a functional decline.

Some of the prime examples of the conditions that meet the CMS CCM requirements include:

• Diabetes
• Hypertension
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure (CHF)
• Chronic Kidney Disease (CKD)
• Depression and other mental health conditions
• Asthma
• Alzheimer’s Disease and Related Dementias
• Osteoporosis
• Cancer (non-terminal)

This wide scope makes our Chronic Care Management overview an essential component in managing today’s growing population of high-stakes patients.

What’s Included in a CCM Program?

Our Chronic Care Management integrates a structure that involves ongoing care coordination that goes above traditional in-person appointments.

• A CCM program provides at least 20 minutes of non-face-to-face care coordination every month, delivered by clinical staff under generic supervision.

• This includes regular check-ups, follow-ups, and personalized patient education.

• A key component is the essential development and continual revision of a comprehensive, individualized care plan that reflects each patient’s medical conditions, goals, and providers involved in their care.

• Additionally, patients have 24/7 access to urgent chronic care support, which enables real-time assistance to manage symptoms and reduce unnecessary visits.

The program consists of chronic disease coordination and communication among various providers, such as specialists, pharmacies, and community resources, to provide an uninterrupted care experience. Altogether, these elements are here to provide a proactive, patient-centric approach that fully supports individual needs with a cross-continuum of care.

Documentation & CMS Compliance Essentials

To guarantee compliance and reimbursement, the CMS CCM requirements require detailed documentation and the implementation of an EHR-certified system. The practices are required to report accurately on the monthly time spent on activities of non-face-to-face care, including check-in and care coordination.

The written or verbal consent and documentation must be acquired before enrolling a patient into a CCM program. Additionally, clinical summaries and regular updates to the individualized care plan need to be documented to capture the patient’s changing needs.

Each patient encounter and care team activity also needs to be documented within the EHR, maintaining transparency and preparedness for audits. This systematic process protects compliance while enhancing the quality and continuity of patient care.

CCM services are billed using CPT codes, including:

• 99490 – At least 20 minutes of non-face-to-face clinical staff time per month
• 99439 – Each additional 20-minute increment
• 99487 – Complex CCM, involving moderate- to high-complexity decision making
• 99489 – Each additional 30 minutes of complex CCM services

Proper tracking and billing ensure your CCM program remains audit-ready and financially sustainable.

See How CCM Works in Your Practice

Chronic Care Management is not only about billing, it’s about creating stronger, more productive relationships with your patients and avoiding the consequences of unmanaged chronic disease.

At RPM & CCM Health, we offer a turnkey, compliant, fully managed CCM solution that is proven to drive improved outcomes. View our full CCM program or schedule an appointment with us.