Chronic Care Management | Remote Patient Monitoring (RPM)
What is CCM and RPM?
Over the past 20 years, the number of chronic diseases has increased steadily. Today, 42% of adults have two or more chronic conditions, and 12% have at least five. The number of adults over 50 with at least one chronic disease is expected to increase from 71.5 million in 2020 to 142.6 million by 2050.
Just seven chronic diseases cause two-thirds of mortality in the US and consume 86% of annual healthcare spending.
Given these trends and research, the Centers for Medicare & Medicaid Services (CMS) launched the Chronic Care Management program in January 2015. This program aimed to improve Medicare beneficiaries’ access to chronic care management in primary care and provide a value-based care model to reimburse physicians for more robust care coordination.
CMS launched Remote Patient Monitoring three years later to enhance chronic disease management with real-time patient data. This supports their goal of making care timelier and avoiding more costly care channels like emergency department visits and hospital admissions.
What is Medicare Chronic Care Management? What are the program’s goals?
Chronic Care Management (CCM) refers to the coordination and oversight of care for patients with two or more chronic conditions that are expected to last at least 12 months or until the patient's death.
A qualified healthcare professional–care manager, nurse practitioner, physician, or other licensed clinical staff—works closely with patients to improve their health outcomes, prevent illness progression, and enhance patient self-management. While only one practitioner can bill and provide oversight for these services, activities may be shared via a clinical team.
This approach focuses on enhancing the efficiency and effectiveness of care by ensuring that patients receive comprehensive and continuous management rather than episodic or reactive care.
CMS requirements for CCM
CMS allows a great deal of flexibility regarding how a care manager or clinician supports patients with two or more chronic conditions. However, in addition to eligibility requirements, there are general and monthly requirements, including:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Initiating visit: New patients or those not seen in 12 months by the rendering provider must have a first visit, during which the patient’s eligibility for the program, any cost-sharing responsibilities the patient may have, and their ability to leave the program at any time are discussed.
- Patient consent: Before joining the program, the patient must give verbal or written consent.
- Minimum time spent: The care team must spend at least 20 minutes each month providing CCM services directly to patients or indirectly by coordinating care.
- Documentation: There must be a record of time spent in the patient’s electronic medical record.
- Practitioner of record: Only one practitioner can bill for monthly CCM services.
- The patient must be provided with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week
How are CCM services paid?
As shown in Figure 1, providers can bill six CPT codes for CCM services. The level of care coordination time is considered non-complex or complex based on the level of medical decision-making and the time required to address the patient’s needs. Complex and non-complex CPT codes cannot be combined in one month.
Figure 1: CPT codes available for CCM services with time requirements and 2024 reimbursement rates.
*The reimbursement rates listed are from the 2024 Physician Fee Schedule. They are based on a national average and may vary by location. See the 2024 Medicare Physician Fee Schedule Final Rule for up-to-date rates.
Effective CCM tools and strategies
Providers and care managers can use various strategies to deliver CCM services and engage patients in chronic condition management. These may include:
- Patient-centric care planning
- Personalized goal setting
- Guided clinical or health risk assessments
- Monthly touchpoints via phone or telehealth
- Ongoing medical supervision and intervention
- Patient education about medical conditions, treatments, self-management
- Annual Wellness Visits
- Advance Care Planning
Vital to engaging patients and eliciting their ongoing involvement is ensuring that CCM participation focuses on patient-centered priorities and helps them adopt new behaviors that further their health objectives. Through monthly touchpoints, ongoing communication, and building rapport, CCM providers help patients build capacity, navigate the healthcare system, and access needed resources.
What is Medicare Remote Patient Monitoring? What are the program’s goals?
The Remote Patient Monitoring (RPM) program reimburses providers for:
- The use of integrated devices that collect and transmit patient clinical data
- The care team’s time to review the data to make changes to the patient’s care plan or intervene if said data indicates an exacerbation that could be detrimental to the patient
CMS developed this program so that providers could have timely clinical information to help them manage patients’ chronic conditions. This can help them provide insight into treatment adherence and health outcomes.
CMS requirements for RPM
While there is some general overlap in requirements with the CCM program—like the initiating visit, patient consent, one billing provider, and documentation—RPM has some distinct differences, including:
- Eligibility requirements: Patients must have at least one acute condition that warrants RPM services. Additionally, only established patients who have been evaluated and have a treatment plan can participate.
- Minimum device readings: Providers must capture 16 daily readings each month.
- Minimum time spent: Providers must spend at least 20 minutes each month providing RPM services, which can include reviewing and analyzing patient data and taking actions related to data insights.
How are RPM services paid?
As shown in Figure 2, providers can bill four CPT codes for RPM services. These codes cover the initial device set-up and education, as well as capturing daily readings and time-based codes for review, analysis, and decision-making based on patient data.
Figure 2: CPT codes available for RPM services with device and time requirements and 2024 reimbursement rates.
*The reimbursement rates listed are from the 2024 Physician Fee Schedule. They are based on a national average and may vary by location. See the 2024 Medicare Physician Fee Schedule Final Rule for up-to-date rates.
How can CCM and RPM programs work together?
CMS encourages providers to leverage both CCM and RPM to help manage patients’ chronic conditions. Utilizing remote patient clinical data in chronic care management gives clinicians real-world insights to identify when they need to intervene, close care gaps, or adjust the care plan.
The data also provides evidence of whether the care plan is effective and patient goals are being met.
CCM and RPM provide a powerful diagnostic-therapeutic combination that has been proven clinically effective and profitable, particularly in treating diabetes and hypertension.
ThoroughCare provides end-to-end care management program software
ThoroughCare is a comprehensive software platform that supports end-to-end workflow and simplified billing for Chronic Care Management and Remote Patient Monitoring.
ThoroughCare provides a structured approach to care management while enabling flexibility to meet individual patient needs. This includes:
- Enrolling new patient participants in CCM and RPM
- Creating and maintaining comprehensive patient care plans
- Ordering, registering, and managing RPM devices
- Coordinating device set-up on behalf of patients to ensure effective care management
- Meeting enrollment and tracking program requirements
- Automating device- and time-based claims documentation for auditing
- Assessing patient symptoms, condition barriers, and care goals to determine planned interventions
- Alerting care teams when RPM data is outside set patient parameters
Key questions answered
What is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare value-based care program that allows healthcare providers to bill for remote care coordination services provided to Medicare beneficiaries. The focus of this program is to provide ongoing care coordination, regular medical supervision, and support self-management for patients with two or more chronic health conditions.
What is Remote Patient Monitoring?
Remote Patient Monitoring (RPM) is a Medicare value-based care program that allows providers to capture and transmit clinical data from patients in their home or community settings using medical devices. The focus of this program is to provide real-time measures as part of ongoing monitoring of a patient’s medical condition, which can be analyzed and used to change the patient’s care plan or intervene if data falls outside of desired boundaries.
Can CCM and RPM be used together?
Yes, provider organizations can use CCM and RPM together if they independently meet each program's requirements. When combined, CCM and RPM provide a robust diagnostic-therapeutic combination that improves chronic condition management, patient health outcomes, and care costs.