A Comprehensive Guide To Chronic Care Management (CCM)

By Prateek Haswani | June 28, 2024

Chronic Care Management (CCM) is a subset of virtual care management that focuses on providing coordinated care to patients with chronic diseases, to improve their health outcomes, quality of life, and minimize healthcare expenditures. With the increasing frequency of chronic diseases across the country, CCM has emerged as a crucial component of modern healthcare.

Chronic care management is defined by the Centers for Medicare and Medicaid Services (CMS) as “care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the patient’s death, and the condition places the patient at the significant risk of death, acute exacerbation/decompensation, or functional decline.”

To put it simply, chronic care management is a focused approach to healthcare that entails the proactive and ongoing management of chronic illnesses by medical professionals with the goal of enhancing patient engagement, improving patient outcomes, and lowering healthcare costs.

Table of Contents

Diagnoses Requirements for CCM Services

The goal of Chronic Care Management (CCM) is to support people who are suffering from two or more chronic diseases that require ongoing medical attention. Remarkably, this criteria applies to about 75% of Medicare beneficiaries. While the precise diagnosis may fluctuate depending on various healthcare policies and contexts, the following are some typical instances of chronic illnesses that are frequently covered under CCM programs:

Diabetes
Hypertension (High Blood Pressure)
Congestive Heart Failure (CHF)
Chronic Obstructive Pulmonary Disease (COPD)
Asthma
Chronic Kidney Disease (CKD)
Mental Health Conditions

CPT Codes For Billing CCM

Billing for Chronic Care Management requires the use of certain Current Procedural Terminology (CPT) codes. CCM’s major CPT code is 99490, which includes at least 20 minutes of non-face-to-face care coordination and management services per month. This includes creating care plans, communicating with other healthcare practitioners involved in the patient’s care, managing medications, and ensuring 24-hour access to care.

Apart from the 99490 code, there are several CPT codes available to bill for extra time or more complex cases:

99491: A qualified healthcare practitioner personally provides CCM services to patients with multiple chronic illnesses for at least 12 months. It calls for a comprehensive treatment plan and at least 30 minutes of professional attention every month.

99437: Additional CCM services for patients who have had several chronic diseases for at least 12 months. This includes extensive care planning and monitoring. This is an-add-on code for 99491. Every additional 30 minutes per month must be personally administered by a qualified healthcare professional.

99490: Initial CCM services for patients with multiple chronic diseases for at least 12 months. The first 20 minutes of clinical staff time each month must be supervised by a Physician or other qualified healthcare practitioners.

99439: This is an add-on code for 99490. For every additional 20 minutes of clinical staff time guided by a physician or other qualified healthcare professional for chronic care management per month.

99487: Initial complex chronic care management services for patients with various chronic conditions that persist at least a year. It entails thorough care planning for chronic conditions requiring moderate to very complex medical decision-making. The first 60 minutes of clinical staff time each month must be supervised by a Physician or other qualified healthcare practitioner.

99489: More complex chronic care management services for individuals with various chronic diseases that have lasted at least 12 months. Every additional 30 minutes of clinical staff time per month must be supervised by a Physician or other qualified healthcare practitioner.

Principal Care Management (PCM) Codes Related to CCM

99424: This code refers to primary care management services for a single high-risk chronic disease that has lasted at least three months. Complex treatment requires frequent drug modifications and practitioner collaboration. The first 30 minutes of care per month must be personally administered by a qualified healthcare professional.

99425: This code covers additional principal care management services for a high-risk chronic disease that lasts at least three months, such as sophisticated care planning, prescription modifications, and continuous coordination. This is an add-on code for 99424, each additional 30 minutes per month must be personally administered by a qualified healthcare professional.

99426: Initial primary care management services for a high-risk chronic disease that lasts at least three months, including complex care planning and prescription modifications. The first 30 minutes of clinical staff time each month must be supervised by a Physician or other qualified healthcare practitioners.

99427: Additional primary care management services for a high-risk chronic disease that lasts at least three months. This is an add-on code for 99426, every additional 30 minutes of clinical staff time per month must be overseen by a Physician or other qualified healthcare practitioners.

Advantages of Chronic Care Management for Healthcare Providers

Enhanced Patient Engagement

Chronic Care Management promotes proactive patient participation through regular communication and follow-up between healthcare providers and patients. This ongoing interaction promotes adherence to treatment goals and a collaborative approach to care.

Patients benefit from more tailored treatment plans, medication management, and continued access to care, which results in higher satisfaction, better health outcomes, reduces hospital readmissions and emergency department visits.

Improved Patient Outcomes

CCM programs can help patients achieve better outcomes by providing continuing care and management for chronic diseases. Regular monitoring, early interventions, and complete care plans and support can help patients stabilize chronic diseases, avoid complications, and improve their overall quality of life.

Streamlined Care Coordination

Chronic Care Management programs can improve communication and coordination amongst healthcare providers involved in a patient’s care. A multidisciplinary approach that includes physicians, nurses, care navigators, and other healthcare professionals ensures that patients receive thorough and coordinated treatment.

Reduced Hospital Readmissions

Effective Chronic Care Management programs can considerably minimize hospitalizations and readmissions by preventing s exacerbations, managing complications, and encouraging preventative care. CCM programs may help stabilize chronic illnesses and treat potential difficulties before they escalate, resulting in fewer hospitalizations and associated healthcare expenses.

Effective Use of Healthcare Resources

CCM promotes proactive management and preventive treatment, which can result in more efficient use of healthcare resources. By emphasizing early diagnosis and intervention, CCM can reduce the need for costly and extensive procedures including hospitalizations, surgeries, and emergency department visits.

Compliance with Regulatory Requirements

Adopting CCM can assist healthcare providers meet regulatory criteria and standards defined by the Centers for Medicare and Medicaid Services (CMS). Providers may guarantee that CCM services are accurately billed, documented, and reported, avoiding penalties and remaining compliant with healthcare laws.

Diversify Revenue Streams

Another advantage of implementing Chronic Care Management is the opportunity to diversify revenue streams through Medicare reimbursements. Providers’ bill for CCM services with specific Current Procedural Terminology (CPT) codes, including 99490, 99487, and 99489. These codes enable healthcare professionals to be reimbursed for non-face-to-face care coordination and management services offered to patients with chronic diseases.

How To Implement A Successful CCM Program?

It is critical to efficiently manage your CCM workflow in order to meet eligible patients’ monthly Chronic Care Management (CCM) needs. The steps below will help you start and implement a CCM program:

Determine Patient Eligibility: Confirm their eligibility and validate their Medicare coverage.
Update the Eligible Patient List: Regularly check and update the list to account for new enrolees and those who are no longer eligible.
Educate Patients: Inform eligible patients about how CCM can help them manage their health conditions and improve their quality of life.
Secure Patient Consent: Obtain patients’ explicit verbal or written consent to complete the enrolment procedure.
Meet Individual Patient Needs: Be proactive in addressing any healthcare-related issues or needs that the patient may have.
Address Social Determinants of Health (SDOH): Identify and address variables such as living conditions, economic stability, and social environment that can affect patients’ health and access to healthcare.
File Claims Efficiently: To ensure correct reimbursement, submit billing information on time and with accuracy.
Ensure Quality and Compliance: Regularly assess the quality of care delivered and ensure that your program complies with all applicable legislation and standards.

Choose HealthArc’s CCM Software For Better Patient Outcomes

Starting a CCM program with an emphasis on virtual care has the potential to greatly improve chronic care management and patient outcomes. HealthArc’s digital health platform enables healthcare providers to establish clear chronic care management goals and outcomes, making it convenient and accessible.

Our CCM software is designed to scale your healthcare results and make patient care and management easy. Our suite of patient communication and interaction capabilities, a dedicated customer success team, clinical software, physician dashboard, and billing capabilities provide a comprehensive solution to establish a successful CCM program.

Please request a free demo to learn about how we can help your organization achieve its care management goals. Also, feel free to talk to our team at +201 885 5571 for any queries.

Frequently Asked Questions (FAQs)

1. What is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a structured approach designed for patients with two or more chronic conditions. It focuses on continuous, coordinated care—extending beyond clinic visits—to improve patient outcomes, reduce hospitalizations, and promote preventive health through ongoing communication, follow-ups, and data tracking.

2. What are the CMS requirements for running a CCM program?

CMS requires that patients have two or more chronic conditions expected to last at least 12 months, a documented care plan, and at least 20 minutes of non–face-to-face clinical staff time per month. Providers must obtain patient consent, ensure HIPAA-compliant documentation, and bill using approved CPT codes such as 99490 and 99439.

3. What are the initial steps to launch a CCM program in a clinic?

Identifying eligible patients through EHR or population health tools
Assigning a multidisciplinary care team
Selecting a compliant digital platform
Developing standardized workflows and care plans
Training staff and communicating program benefits to patients
A pilot phase is recommended to test processes before full rollout

4. How do I build an effective care team for CCM?

An effective CCM team includes physicians, registered nurses, medical assistants, care coordinators, and pharmacists. Each member should have defined roles—such as patient outreach, medication management, documentation, and clinical follow-up—to ensure continuity and efficiency.

5. How do I identify and enroll eligible patients at CCM?

Use EHR data to filter patients with multiple chronic conditions like diabetes, hypertension, or COPD. Educate patients on program benefits, gain consent, and automate enrollment using your digital platform. Population health dashboards and outreach tools simplify this process significantly.

6. What virtual care infrastructure do I need for CCM?

A successful CCM program requires a HIPAA-compliant digital health platform that integrates with EHRs, supports telehealth (audio/video), enables secure messaging, tracks clinical activity, and automates documentation and billing workflows. HealthArc’s digital platform offers all these capabilities under one system.

7. How should care plans and protocols be developed?

Create standardized, condition-specific care plans that include measurable goals, medication management, self-care instructions, and escalation protocols. Care plans must be updated regularly to reflect patient progress and any new clinical findings.

8. How can Remote Patient Monitoring (RPM) enhance a CCM program?

RPM complements CCM by collecting real-time patient data from devices like glucometers, BP cuffs, or weight scales. This continuous monitoring helps providers intervene early, adjust treatment plans, and engage patients more effectively between appointments.

9. What are the most common chronic diseases managed through CCM?

Common conditions include diabetes, hypertension, heart disease, asthma, COPD, obesity, arthritis, and mental health disorders. CCM works best when addressing conditions that require long-term medication adherence and continuous support.

10. How do I coordinate care effectively within CCM?

Assign dedicated care coordinators to handle outreach, follow-ups, medication tracking, and communication. Shared dashboards allow clinicians to collaborate in real time and keep all stakeholders informed on each patient’s progress.

11. How much time is required per patient each month under CCM?

CMS guidelines require a minimum of 20 minutes per patient per month of non–face-to-face care coordination. Additional time-based codes can be billed if more work is performed, such as in complex or multi-condition cases.

12. How can clinics maintain patient engagement in CCM?

Sustained engagement depends on consistent communication and personalization. Use telehealth visits, reminders, educational content, and satisfaction surveys. Encourage patients to share feedback and actively participate in their care plans.

13. Can CCM workflows be automated with technology?

Yes. HealthArc automates many CCM workflows, including patient enrollment, time tracking, billing, alerts, and care documentation. Automation reduces administrative burden, improves accuracy, and ensures compliance with CMS audit standards.

14. How do CMS billing rules apply to chronic care management?

Providers can bill for CCM using CPT 99490, 99439, 99487, and 99489 depending on complexity and time spent. Documentation must demonstrate clinical relevance, consent, and completed care coordination activities.

15. How can practices measure ROI from a CCM program?

ROI can be measured through increased revenue from CMS reimbursements, improved clinical outcomes, reduced hospital readmissions, and enhanced patient satisfaction. Most practices see returns within 3–6 months of implementation.

16. What metrics should be tracked to gauge program success?

Patient enrollment and retention rates
Clinical improvements (BP, glucose, and A1C levels)
Patient satisfaction
Avoided hospitalizations and ER visits
Staff productivity and care coordination time

17. What are common pitfalls to avoid when implementing CCM?

Avoid undertraining staff, using non-integrated tools, or lacking clear documentation workflows. Ensure all team members understand CMS guidelines, care plan updates, and communication protocols to prevent compliance issues.

18. Can CCM reduce hospital readmissions and costs?

Yes. By enabling early intervention, continuous monitoring, and proactive communication, CCM significantly lowers hospital admissions and emergency visits—improving overall care quality while reducing long-term healthcare costs.

19. How do you train staff to adopt CCM workflows?

Staff training should cover CMS rules, patient communication, record-keeping, and technology use. Role-based onboarding ensures care coordinators, nurses, and physicians all follow standardized workflows.

20. What compliance and privacy considerations apply to CCM?

CCM programs must adhere to HIPAA rules for patient data protection and CMS rules for billing compliance. Platforms like HealthArc follow all regulations through secure data encryption, access controls, and audit logs.

21. What are best practices for patient onboarding in CCM?

Ensure onboarding is straightforward and transparent. Explain the program benefits, how data will be used, privacy protections, and provide easy registration steps. Encourage patients to communicate with their care team.

22. What challenges do practices face when scaling CCM?

Scaling challenges include staffing limitations, inconsistent patient engagement, and fragmented systems. A unified digital platform helps overcome these through automation and centralized coordination.

23. What kind of software or platform is ideal for CCM?

An ideal platform supports EHR integration, time tracking, RPM data capture, billing, telehealth, and reporting. HealthArc’s CCM solution provides all capabilities in a secure, scalable, and compliant interface.

24. Is CCM suitable for small practices or only large health systems?

CCM is scalable and beneficial for both small practices and large systems. Smaller clinics can outsource care coordination or use software automation to manage programs efficiently without large overhead.

25. What makes HealthArc’s CCM solution different?

HealthArc’s CCM platform combines care coordination, remote monitoring, billing automation, and analytics under one HIPAA-compliant solution. It’s customizable, integrates with major EHRs, and simplifies CMS compliance—helping practices deliver better outcomes and maximize reimbursements.

Tags: #ccmbilling, #ccmcodes, #chroniccarecodes, #chroniccaremanagementprogram