Chronic Care Management supports patients in managing their chronic conditions, preventing future illness, slowing disease progression, and avoiding exacerbation.
A CCM program typically includes a variety of services proven to support chronic disease management, including:
CCM facilitates effective management of chronic conditions—such as diabetes, hypertension, heart disease, and cancer—through personalized care planning, routine monitoring, and enhanced patient engagement.
This program is available to eligible Medicare beneficiaries, and reimburses providers for delivering direct or supervised remote care.
Medicare has three overarching eligibility requirements for the CCM program. The patient must:
Beyond these patient qualifications, providers must meet several requirements to support patient eligibility and enroll them in the CCM program.
The initiating visit: New patients or those not seen in 12 months must have an initiating visit, during which their provider will inform the patient of their eligibility for the program and the benefits of enrolling.
Note that the initiating visit can happen during a comprehensive face-to-face evaluation and management (E/M) appointment or an Annual Wellness Visit (AWV). However, if the practitioner does not discuss CCM during an E/M visit, AWV or IPPE, that visit cannot be considered the initiating visit.
Informing the patient: During the initiating visit, the patient’s practitioner is required to notify the patient about crucial points related to the CCM program, including:
Related to cost, Medicare Part B covers the CCM service; however, beneficiaries may be responsible for cost-sharing, which could include a 20% coinsurance, copayment, or deductible. Medigap policies may help pay this cost.
Obtaining consent: Before joining the program or being billed for CCM services, the patient must give verbal or written consent, documented in their medical record.
Based on Medicare’s patient eligibility requirements, providers can use clinical and utilization details to identify a cohort that could benefit most from CCM services.
The Centers for Medicare & Medicaid Services (CMS) suggests criteria, including:
The American Academy of Family Physicians (AAFP) suggests several approaches that practices can use to identify the most appropriate patients that qualify for CCM services.
Key to identifying and triaging patients for Chronic Care Management is:
Providers can manage care management programs effectively with ThoroughCare. As a comprehensive software platform, ThoroughCare streamlines care management across all program types by automatically accounting for Medicare’s rules and requirements while documenting service records.
Our end-to-end workflow simplifies program oversight, service delivery, and billing for Chronic Care Management. It provides a structured approach and evidence-based tools while enabling flexibility to meet individual patient needs.
Original Medicare beneficiaries qualify for CCM services. They must have two or more chronic conditions. They are expected to last at least 12 months or until the patient’s death or that place them at significant risk of death, acute exacerbation or decompensation, or functional decline.
The provider overseeing their care would need to meet requirements related to an initiating visit. This is where the patient is informed about cost-sharing responsibilities, their right to leave the program at any time, and that only one physician may bill for CCM services each month. The patient must give written or verbal consent, documented in the medical record.
Providers can use existing data from their electronic medical records to risk stratify their patient roster. They can use this data to identify a cohort that could qualify for and benefit from CCM services. Criteria to consider when identifying potential CCM patients include the number of chronic illnesses, prescribed medications, and repeat hospital admissions or emergency visits. Other factors could also merit CCM value, such as the number of specialists and lack of community or at-home support.