Skip to main content
Chronic Care Management

A Comprehensive Guide to
Chronic Care Management

Learn about the benefits and requirements of this Medicare program.

 

 

What is Chronic Care Management?

A monthly touchpoint to coordinate patient care

CCM is a Medicare Part-B program for patients with two or more chronic conditions. Clinical staff engage patients for at least 20 minutes per month to coordinate care activities.

Studies have shown that CCM programs can reduce hospital admissions and cut health costs in the long term. Providers are also reimbursed per patient for offering the service. 

Square v1_Security & HIPAA

For patients with two or
more chronic conditions

Common conditions include but are not limited to:

  • Alzheimer’s disease and related dementia
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS
Square v1_Who We Support-Home Health-1

Patients benefit from coordinated care and increased engagement

Patients work with care managers to achieve desired health outcomes. This all revolves around a patient-centered care plan.

CCM services include a monthly clinical review, telephone check-ins, physician reviews, referrals, prescription refills, chart reviews and scheduling appointments or services.

Qualified providers span care teams

CCM billing must be directed by a provider with an NPI number. That said, a diverse set of licenses can deliver the program, including:

  • Physicians
  • Physician assistants
  • Nurse practitioners
  • Certified nurse midwives
  • Clinical nurse specialists
  • Pharmacists

Read an Article

Square v1_Platform Integration

Eligibility depends on requirements

A patient must have two or more chronic conditions to enroll in a CCM program. These diseases must: 

  • Be expected to last at least 12 months or until end-of-life
  • Post a risk of death, acute decompensation or functional decline
  • Be noted by the provider 12 months prior to enrollment

How do patients enroll in CCM?

Enrollment is completed at an in-person evaluation or Annual Wellness Visit. Written or oral consent must be documented.

The provider should explain to the patient:

  • How CCM can benefit them
  • Medicare Part-B's 80% coverage with co-pay
  • That they can opt out at any time
Square v2_Web App-2



Understanding Chronic Care Management CPT codes:
99490, 99491, 99439, and more

2024 - CCM - Chart 1 - Final


Different CPT billing codes reflect specific categories of CCM.  The qualifying determinants are who provides program services, complexity of medical decision-making, and the length of time spent with the patient.

 

CPT Codes for Non-complex Chronic Care Management

Billing code assignment is based on the complexity of medical decision-making. 

As shown in the graphic above, CCM billing codes specify Complex and Non-complex chronic care services. Within these categories, codes further reflect different lengths of time spent with patients and the level of physician involvement required. 

In some instances, Non-complex CCM can be provided by clinical staff. 

For Non-complex CCM, the following CPT codes can be used to account for reimbursement based on all program requirements being fulfilled.  

  • CPT code 99490 for 20 minutes of billable time 
  • CPT codes 99490 + 99439 for 40 minutes of billable time 
  • CPT codes 99490 + 99439 (x2) for 60 minutes of billable time 

Two ICD-10s must be presented when billing for chronic care services as the requirement for CCM includes two or more present conditions.

CPT Codes for Physician-Driven, Non-complex Chronic Care Management

The following codes are designed for non-complex chronic care in which the provider or non-physician practitioner (NPP) is heavily involved. They cannot be billed concurrently with standard CCM CPT codes (reviewed in the prior section).

The value of physicians’ time is reflected in these non-complex, physician-driven codes as CCM services are not reliant on clinical staff:

  • CPT code 99491 for 30 minutes of billable time 
  • CPT codes 99491 + 99437 for 60 minutes of billable time 

CPT Codes for Complex Chronic Care

The following billing codes apply for complex care:

  • CPT code 99487 for 60 minutes of billable time
  • CPT codes 99487 + 99489 for 90 minutes of billable time 

It is important to note the distinction between CPT code 99487, which accounts for 60 minutes of complex chronic care, versus the two CPT codes (99491 and 99437) that account for 60 minutes of physician-driven, non-complex chronic care.

In the case of a Medicare audit, you will want to show the correct code was applied based on the compatible situation.

To bill for CCM, providers must meet specific requirements

Delivered through remote interactions, either by phone or a telehealth platform, CCM is billable when at least 20 minutes are spent with the patient performing appropriate tasks. CCM services can include:

  • A monthly clinical review
  • Telephone calls
  • Physician reviews
  • Referrals
  • Prescription refills
  • Chart reviews
  • Scheduling appointments or services

Providers can successfully submit
Chronic Care Management claims by:

CCM Rules - Provider Expectations-1

How to start a CCM program

Before starting a chronic care program, it's important to consider: 

  • Your plan to enroll and deliver services to patients
  • Hiring a certified care manager
  • Targeting a specific population or conditions
  • Using software to manage care planning and billing

Initial steps to launching a CCM program

Apart from understanding CCM's rules and requirements, providers should:

Care managers engage patients and facilitate CCM program services

Care managers play a crucial role in delivering care management services to patients. They conduct a majority of patient engagement and execute nearly all program services.



Chronic Care Management can promote value-based care

An aging, chronically ill population calls for wide adoption of CCM

CCM can be a versatile tool to maximize care quality and performance.

Though it's a fee-for-service program, CCM can help providers address value-based care objectives without sacrificing financial stability.

Read an Article

Square v1_Training & Onboarding

Patient engagement is
essential to closing care gaps

Care gap closure isn’t about checking a box.

CCM programs can help patients understand the value of prevention throughout every phase of life.

Read an Article

Square v2_Web App-2

SMART goals can personalize care planning for disease management

Goal-oriented care engages patients in identifying their personal objectives and aligning their care with these desired outcomes. 

Watch a Video

Square v1_Improve Patient Engagement-1 purple

Payors and providers use CCM
to reduce healthcare costs

According to Highmark Health, payors and providers can use CCM to save more than $800 per case, reducing readmission and inpatient days, as well as lowering post-acute utilization rates.

Read an Article

Square v1_Enabled Coordinated Care-1a

MetaPhy Health uses software to deliver Chronic Care Management

Since 2017, ThoroughCare has helped MetaPhy Health optimize care delivery for patients with multiple chronic conditions. 

Learn how MetaPhy Health uses our care coordination platform. 

Watch a Case Study

thumbnail_metaphy_case_study with play

Chronic Care Management can improve rural healthcare quality

CCM programs can directly influence and support quality improvement efforts, leading to better health outcomes and performance measures, as well as value- or performance-related financial incentives. For rural communities, a CCM program can capitalize on providers’ strengths in nurturing personal relationships and maximizing limited resources.

They can leverage close ties to the community and collaborate toward quality improvement efforts.

Read an Article

Square v2_ValueBasedCare 1

Research shows CCM's impact

A Chronic Care Management program in West Virginia was so successful that it was scaled to three states, including 11 Federally Qualified Health Centers and three rural hospitals. This program leveraged community health workers to support patients living with diabetes and achieved improved health, including:

  • 63% achieved a lowered HbA1c
  • 21.5% decreased their HbA1c below 10%
  • 22% decrease in emergency room visits
  • 30% decrease in hospitalizations
  • Annual cost savings of $384,000
Square v2_Improve Patient Engagement-2

Studies show CCM enhances care

Studies highlight specific ways CCM enhances care quality, including:

  • Improved patient self-management
  • Increased interdisciplinary and team coordination 
  • Decreased healthcare utilization like hospital admissions/readmissions and emergency room visits
  • Providers can focus more on identifying and addressing patients’ health goals and care preferences
  • Improves routine screening and preventative treatment rates
  • Better coordination of care transitions
  • Improved clinician and service satisfaction surveys
  • Better understanding of recommended therapies and adherence
Square v2_Who We Support-Home Health-2_v2

Using HCPCS code G0511 for CCM

Rural health clinics and federally qualified health centers utilize this HCPCS code for "general care management” to bill for Chronic Care Management.

This code can be billed for multiple care management services per month, including Remote Patient Monitoring and Behavioral Health Integration. However, all service requirements and accounting must be met separately. 

Read an Article

g0511

CCM can be combined
with other Medicare programs

This can further support patient outcomes and generate additional reimbursement.

Support chronic conditions
with behavioral healthcare

Clinicians and healthcare policymakers are accepting that physical and mental health are closely interconnected.

This view is now influencing the aims and focus of value-based care through Chronic Care Management, care coordination, and Behavioral Health Integration.



Pharmacies can increase access to Chronic Care Management

Providers can partner with pharmacies for program delivery

Primary care shortages, value-based contracting and increasing chronic illness call for pharmacists to have an expanded role. 

Through partnerships, providers can work with pharmacies to streamline care management and improve patient engagement.

Pharmacists are uniquely positioned and skilled for CCM

  • Accessibility: Ninety percent of people in the US live within five miles of a community pharmacy.
  • Frequency: Patients interact with their pharmacist up to 12 times more frequently than their primary care physician.
  • Skills: Pharmacists have counseling and education skills that support CCM activities.
  • Chronic illness: Pharmacists understand many aspects of chronic diseases and their interactive influences.
  • Drug therapy: Pharmacists are drug therapy management experts, which is crucial because most chronic illnesses require multiple medications.

Read an Article

Square v2_Enabled Coordinated Care-2

ThoroughCare streamlines
Chronic Care Management

Our software platform is intuitive and designed for CCM’s rules and requirements. ThoroughCare can help providers:

  • Facilitate patient consent and enrollment
  • Manage the entire CCM function
  • Create and maintain goal-driven care plans
  • Simplify claim submission and documentation requirements
  • Integrate with leading EHRs for holistic patient records

Request a Software Demo View Solution

ccm dashboard