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Chronic Care Management: Benefits, Requirements, & Reimbursements for Providers

Jon-Michial Carter
Written by Jon-Michial Carter

In the United States, around 60% of adults have one chronic condition, about 40% have two or more, and nearly half of the population over 75 years of age have three or more. Living with chronic illnesses creates a mental, physical, and financial burden for patients and leads to higher costs and complexity for their providers. 

According to the CDC, chronic disease is the leading cause of death and disability and the leading driver of $4.1 trillion in annual healthcare costs in the US. 

Patients with multiple chronic conditions often have a broader network of providers and more prescribed medications, increasing their risk of hospitalization and gaps in care due to inadequate care coordination.

Implementing Chronic Care Management (CCM) is one of the best ways to offset these ramifications. Medicare’s CCM program addresses two interrelated pain points: rising health risks for the chronically ill and a lack of reimbursement to engage providers in preventative health management. 

However, many practices and physicians hesitate to adopt CCM due to insufficient knowledge, time, or staffing. At ChartSpan, we’ve identified the complexities of Chronic Care Management and have perfected our processes to provide a fully managed CCM service that imposes no added burden on your practice resources. In this guide, we’ll explain the challenges and benefits of Chronic Care Management, how to get started, and how to maximize reimbursements. 

What is Chronic Care Management?

Chronic Care Management is a value-based Medicare program that reimburses providers for coordinating services beyond regular office visits for beneficiaries with two or more chronic conditions. CCM aims to improve patients’ quality of life, assist in managing symptoms, prevent complications, and promote patient self-management across healthcare and community settings.

Chronic Care Management services include personalized care plans, 24/7 remote access to healthcare professionals, prescription and appointment assistance, care coordination with specialists, assistance during transitions between healthcare settings, and patient education to foster self-management. CCM programs also require electronic health record (EHR) systems for seamless patient information sharing across providers.

CCM programs have demonstrated positive health outcomes for enrolled patients and additional revenue for providers when executed at scale. By offering a structured and coordinated approach to care, these programs not only enhance the patient experience but also lead to reduced hospital readmissions, fewer emergency room visits, and better chronic disease management. Additionally, providers benefit from a consistent revenue stream through Medicare reimbursements. 

The collaborative nature of CCM ensures that patients and healthcare providers are aligned in their goals, driving overall improvements in the healthcare landscape.

What is the purpose of Chronic Care Management?

CCM’s primary purpose is to provide coordinated and preventive care for chronically ill patients while reducing healthcare costs and compensating providers for their services. 

CCM and care coordination

The number of providers seen and the complexity of treatment increases for patients with multiple chronic conditions. In addition to a primary care provider, these patients frequently need to visit specialists. Their quality of care and success in managing their conditions relies on coordination between their various providers. 

For instance, if a patient takes medication for cardiovascular issues, all other healthcare providers should know about that medication to avoid prescribing additional medication that might interfere with their treatment.

CCM programs or software should integrate with the EHR so providers can share and access patient information easily. This ensures that patients’ complete medical history, test results, and other essential data will be readily available.

Regular communication between patients, primary care providers, specialists, care coordinators, and other healthcare professionals is a cornerstone of CCM. This constant dialogue ensures that all parties are informed about a patient's status, changes in treatment, or emerging needs. 

CCM and preventive care

Chronic conditions typically last for a lifetime and may not have a cure. People with chronic illnesses often need ongoing medical care to manage their symptoms and slow down the progression of the disease. Since Chronic Care Management is a monthly program, it emphasizes preventative measures to proactively address chronic conditions and prevent exacerbation and subsequent health issues in between regular office visits.

CCM and reduced healthcare spending

CCM coordinators prevent costly complications and hospital readmissions by regularly monitoring patients and ensuring consistent communication among providers. Additionally, by streamlining care, CCM reduces redundant tests and procedures for efficient use of resources. CCM's integrated approach not only enhances patient health outcomes but also leads to significant savings in the broader healthcare system.

CCM and provider reimbursement 

Before 2015, Medicare did not reimburse providers for their time devoted to Chronic Care Management outside of office hours. This limitation placed a financial strain on providers and risked the quality of care for many beneficiaries with chronic conditions. 

Recognizing this gap, Medicare introduced billing codes in 2015 to compensate providers for non-face-to-face CCM services, underscoring the program's commitment to comprehensive and coordinated patient care.

CCM qualifying conditions

To qualify for CCM, Medicare patients must have two or more chronic conditions that put the patient at risk of decompensation, functional decline, or death. These conditions are expected to persist throughout the patient's life.

Some common examples of chronic conditions include but are not limited to:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS
  • Osteoporosis
  • Schizophrenia and other psychotic disorders
  • Stroke

Learn more about the conditions that qualify for CCM.

Chronic Care Management requirements and services

Medicare provides reimbursement for CCM services, but only when providers meet specific requirements. The stipulations in CCM ensure that patients with multiple chronic conditions receive consistent, comprehensive, and coordinated care. Adhering to these requirements helps prevent care gaps, reduce medical errors, and ensure a standardized level of care quality.

Patient eligibility

In addition to having two or more chronic conditions, Medicare patients must have visited their healthcare provider within the past year to be eligible for CCM. They can only be enrolled in a CCM program under one provider. 

Patient consent 

Since patients are typically required to pay a small monthly copay for CCM, it's essential to tell the patient about their copay and obtain documented patient consent before enrollment. Additionally, CCM vendors should inform patients about the specifics of CCM services, their right to unenroll at any time, and details regarding when and how the CCM vendor and healthcare providers will share data with each other. At ChartSpan, we record and archive all patient consents for 10 years and provide detailed CCM information and a copay estimate before asking for consent. 

Patient education

CCM providers must educate patients about their conditions, risk factors, and self-management techniques. Knowledgeable patients can take proactive steps in their daily lives to prevent complications and maintain optimal health.

Personalized care plans

Each patient should receive a personalized care plan that maps out preventive strategies specific to their unique health profile. The plan may include scheduled screenings, lifestyle recommendations, timely medication adjustments, and an inventory of resources and individuals involved in the care. The care plan should be available in the EHR and to patients. 

24/7 access to care

CCM programs provide patients with access to healthcare professionals 24/7. This constant availability guarantees that patients receive immediate guidance on any concerning symptoms or situations and reduces the chances of conditions escalating due to delays in care.

Monthly touchpoints

CCM programs should provide patients enrolled in a CCM program with at least 20 minutes of non-face-to-face care each month. They will conduct monthly check-ins to review and manage the patient's conditions over the phone or other digital methods. 

Medication management

CCM ensures that patients consistently take their medications and keeps providers updated on a patient's treatment regimen to avoid potential drug interactions.

Referral management 

A CCM program coordinates referrals to other providers, ensures timely follow-ups, and documents the findings into the patient's care plan.

Electronic Health Records (EHR)

Pushing CCM documentation to the EHR  keeps patients’ health information updated, ensuring that all care team members have consistent, up-to-date data.

Care coordination

Coordinating care involves sharing patient care plans and treatment history with other approved healthcare professionals. It also encompasses transitions between care settings, like moving the patient from a hospital to a home or a nursing facility.

Lifestyle recommendations

CCM often incorporates education for diet, exercise, stress management, and other lifestyle factors that play a role in preventing and managing chronic diseases.

Vaccinations and screenings

Based on the patient's health profile, CCM coordinators can recommend and schedule regular screenings and vaccinations to prevent associated conditions or complications. Regular check-ins identify gaps in care so providers can address them efficiently.

Support for self-management

Providing patients with resources and tools, including training to monitor their conditions or correctly use their medications, empowers them to self-manage their conditions.

Connection to community resources

CCM addresses Social Determinants of Health (SDOH) by guiding patients to relevant community-based services and resources. This supports their immediate needs like housing, food security, education, and social connections, all of which play vital roles in enhancing their overall quality of life.

For many providers, outsourcing Chronic Care Management is the most feasible and successful way to extend these services to patients outside of in-office visits. For example, ChartSpan can identify, enroll, and educate patients in your CCM program. We provide them access to a 24/7 nurse call line and spend 20 minutes with each patient every month to assist them in managing their chronic conditions. 

Challenges of Chronic Care Management

1. Getting started

Establishing a CCM program may require significant changes in practice workflows, systems, and culture. Starting the program can be daunting, especially for smaller practices needing more resources or expertise to launch such programs effectively.

2. Enrollment 

Identifying and enrolling eligible patients requires understanding the specific criteria for CCM and often involves manual filtering. The administrative work associated with the enrollment process takes time and effort, and never ends. Your practice must continue to maintain patient enrollment lists to add new patients and remove patients who’ve passed away or are no longer eligible. 

3. Patient copay 

CCM services come with a copay for patients. Under Medicare Part B, patients pay a monthly premium of $164.90 and a $226 deductible. They’re then usually responsible for 20% of the cost of CCM or any other Medicare Part B services. Depending on the patients’ primary and secondary insurances, their cost can vary.

Communicating the value of the service to patients and justifying the added cost can be challenging. Some patients might decline the service due to the additional expense. Some providers feel that explaining the copay to patients is a burden and may damage the trust their patients have for them. 

4. Increased workload

The continuous monitoring, documentation, and care coordination associated with CCM adds to the workload of healthcare professionals, which can be particularly overwhelming if a practice lacks the infrastructure and staffing to handle the additional demands. 

Physicians often need more time and bandwidth to call patients regularly between office visits. Additionally, practices often lack the staff to devote to enrolling and educating patients and maintaining eligible patient lists. 

5. Technical resources required

Implementing CCM means having the appropriate electronic health record (EHR) systems, telephonic system, reporting, and other technology tools. This might necessitate substantial investments in technology and training for your practice.

6. Billing complexities

CCM billing involves specific codes, documentation requirements, and comprehension of billing rules. Misunderstandings or errors can lead to claim denials or compliance issues. Forty-three percent of providers who participated in a survey said they had not implemented a CCM program because of the complex coding. 

7. Compliance and quality assurance 

Medicare has strict regulatory and operational requirements for CCM, and your practice must always comply to earn reimbursement. To ensure that the CCM program achieves its intended outcomes, you must set up and maintain quality assurance processes, which include documenting patient calls and feedback and conducting routine audits.

8. Disparate EHRs

If a patient sees multiple providers using different EHR systems, it can be challenging to coordinate care. Providing 24/7 access to the patient care plan becomes complex when sharing between separate EHRs. 

Learn more: Challenges in Delivering Quality Care to CCM Patients

Solution: A full-service CCM provider

Managing a CCM program can be intricate and often challenging to scale for many practices. When partnering with a full-service Chronic Care Management provider, you can amplify the quality of patient care without complicating your existing workflow.

At ChartSpan, we streamline the patient enrollment and consent process, eliminating the need for you to interrupt regular office visits discussing copays or juggling enrollment responsibilities. Our focus is to educate patients about the immense value of CCM and be their steadfast support in managing their conditions. 

When you partner with ChartSpan, we become an extension of your care team. We guarantee a minimum of 20 minutes of constructive engagement with each patient monthly, offering support from facilitating medication refills and transportation to ensuring smooth care transitions. Additionally, we connect patients to community services and tools to address their Social Determinants of Health (SDOH).

Our adept professionals are trained to navigate billing complexities, ensuring you capture the full revenue potential of CCM. Our CCM systems also integrate with your EHR to improve care coordination and maintain quality assurance. 

With ChartSpan, you can focus on what you do best—providing top-notch care—while we handle the intricacies of CCM.

Benefits of Chronic Care Management

1. Positive patient outcomes

CCM provides a structured and consistent approach to managing chronic diseases. Regular check-ins and individualized care plans can help control symptoms and slow the progression of illness. With CCM, your practice can promptly identify and address potential complications or exacerbations of a condition to reduce the severity or frequency of acute episodes.

2. Additional revenue 

The Chronic Care Model rewards quality of care rather than quantity of care. By offering CCM services, your practice can tap into new value-based revenue opportunities through Medicare reimbursements. This approach elevates the quality of patient care while strengthening your practice's financial position. 

3. Reduced hospitalizations

Patients enrolled in a CCM program show remarkable improvement in managing their chronic conditions compared to those not enrolled. 

One Accountable Care Organization (ACO) experienced a 20% decrease in hospital admissions and a 13% decrease in emergency room visits for enrolled CCM patients. Interviews with 71 healthcare professionals revealed decreased hospitalizations and emergency department (ED) visits as a positive outcome of CCM. 

4. Adherence to care plans

CCM keeps patients on track with their treatment regimens by providing resources, guidance, and regular check-ins. When patients consistently follow their care plans, they significantly reduce the risk of complications, ensuring their treatment trajectory remains on the desired path. Healthcare professionals admit having an accessible care plan aids their decision-making and communication with patients. 

5. Increased patient engagement 

By involving patients in their care decisions, offering them the necessary education, and equipping them with self-management tools, CCM transforms them from passive recipients of care to active participants in their health. An informed and engaged patient is more likely to make beneficial health decisions, leading to better outcomes and a heightened sense of ownership over their health journey.

6. Greater access to care

CCM offers uninterrupted access to care. By incorporating telephonic services and ensuring that patients can connect with healthcare professionals 24/7, CCM breaks down barriers to healthcare like transportation or timing. This around-the-clock access ensures patients receive timely guidance, drastically reducing potential health risks and granting them invaluable peace of mind.

7. Improved care coordination 

CCM prevents potential treatment overlaps or conflicts by providing consistent communication and alignment among all caregivers. This holistic, unified approach ensures that your practice considers every facet of a patient's health, leading to more comprehensive and effective care.

Learn more: The Effectivity of CCM Programs

Chronic Care Management reimbursements

Medicare aims to improve patient outcomes, reduce hospitalizations, and ultimately achieve a more cost-effective healthcare system through reimbursements. CCM reimbursements compensate providers for the time and resources used to manage and coordinate care outside of in-person patient visits.

Reimbursement rates vary by state and practice type, but a positive revenue stream is achievable with proper billing practices, even with a smaller patient population. For example, an RHC practice in Mississippi that partnered with ChartSpan to enroll 400 patients in their CCM program realized more than $161,000 in annual net profit.

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) receive higher reimbursements due to their unique challenges in caring for underserved populations. This enhanced financial support aims to ensure these clinics can offer comprehensive and continuous care to vulnerable people, counteracting socio-economic and accessibility barriers and promoting overall community health.

Learn more: CCM for RHCs and FQHCs

Outsource CCM enrollment to maximize reimbursement

CCM revenue will ultimately depend on the volume of patients enrolled, so it’s essential to have a robust system to obtain patient consent for participating in your CCM program. Outsourcing this critical function to a CCM partner will help you maximize reimbursements. 

ChartSpan has discovered that employing a dedicated team of Enrollment Specialists skilled in articulating the advantages of Medicare’s CCM services and adept at addressing prevalent patient concerns is the most effective approach to patient enrollment. Our methods yield impressive results: 60% of eligible patients enroll, while most practices that attempt an in-house CCM program enroll only 10% of their eligible patients.

Learn more: How to Build a Recurring Revenue Model for Your Practice with CCM

How to bill for CCM

Enrolling eligible patients, obtaining their consent, providing a comprehensive care plan, and incorporating non-face-to-face CCM services every month are all prerequisites to billing for CCM. Before beginning the billing process, familiarize yourself with CCM billing rules

When billing for CCM, follow these steps:

  • Track time: For CCM billing, accurate records of the time spent providing non-face-to-face care coordination services are crucial. 
  • Use proper codes: Medicare has designated CPT codes for CCM services. Commonly used codes include:
    • CPT 99490: For at least 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified healthcare professional per calendar month.
    • CPT 99439: Each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
    • CPT 99491: Billed by the physician for at least 30 minutes of direct care by the physician without counting staff time.
    • CPT 99487: For complex CCM that requires at least 60 minutes of clinical staff time.
    • CPT 99489: Add-on code for each additional 30 minutes of clinical staff time.
    • G0511: Billed by RHCs and FQHCs for CCM services under HCPCS (Healthcare Common Procedure Coding System) 
    • ChartSpan focuses on codes 99490, 99439, and G0511.
  • Maintain documentation: Document all CCM services, including time logs, care plan changes, communication with other care providers, and any patient or caregiver communication.
  • Submit claims: Submit the claim to Medicare. Ensure that your billing claim includes the appropriate CCM CPT code(s), patient information, and service date.
  • Monitor for denials and adjustments: After submitting, keep an eye on any denials or requests for additional information from the payer. Address any issues promptly to ensure payment.
  • Stay updated: Reimbursement rates are set annually in the Physician Fee Schedule. Ensure you know of any alterations in CCM billing requirements or reimbursement rates.

ChartSpan can streamline your CCM billing with our RapidBill™ software. Our dedicated client team is at your service for billing queries, managing claim denial appeals, and ensuring you achieve your revenue targets. We also prioritize and continually monitor quality performance, ensuring that your practice reaps the full advantages of a successful CCM program.

Who’s responsible for CCM billing?

Several types of healthcare practices, including primary care and specialty, can offer a CCM program to their patients. CMS allows physicians, nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives, and other qualified health care professionals to bill for CCM services. Healthcare professionals who aren’t physicians should perform CCM services under the general supervision of a physician.

Learn more: Ten Things You Should Know Before Billing CPT 99490

How to get started with Chronic Care Management

Efficiently managing your CCM workflow is crucial to ensure that your clinic consistently meets every eligible patient's monthly Chronic Care Management requirements. 

Follow these steps to kickstart and maintain your CCM program–or trust your CCM partner to undertake them for you. 

  1. Identify eligible patients: Before enrolling a patient in a program, you must confirm their eligibility and verify their Medicare insurance. You must also check that the patient has had at least one consultation with their provider in the preceding year. 
  2. Update the eligible patient list periodically: Regularly review and maintain the list to account for new enrollees and those no longer eligible. A patient's eligibility can change if they pass away, move to a nursing home, or experience significant changes in their health conditions.
  3. Educate patients: Educate eligible patients about how CCM can assist them in better managing their health conditions and improving their quality of life.
  4. Secure patient consent: Before initiating CCM services, obtain explicit verbal or written consent from patients and complete the enrollment process.
  5. Engage in monthly conversations: Ensure a minimum of 20 minutes of meaningful interaction with each enrolled patient every month to discuss and manage their health needs.
  6. Assist with individual patient needs: Be proactive in addressing any healthcare-related concerns or needs the patient may express.
  7. Address Social Determinants of Health (SDOH): Recognize and address factors like living conditions, economic stability, and social context, which can influence patients' health and access to healthcare.
  8. File claims efficiently: Submit billing information timely and accurately to ensure proper reimbursement.
  9. Ensure quality and compliance: Regularly monitor the quality of care provided and ensure your program complies with relevant regulations and standards.

Integrating a CCM program can be overwhelming for one practice to manage alone. Instead, work with a team built for managing CCM. 

Partnering with ChartSpan for CCM can significantly enhance the efficacy and efficiency of your program. Our experience and expertise can guide your clinic through the intricacies of CCM, ensuring optimal outcomes for your patients and the practice.

Learn more: 10 Myths of Running a CCM Program

Choosing a CCM vendor

Choosing a chronic care management (CCM) vendor is a critical decision that can significantly influence patient outcomes, operational efficiency, and revenue generation for healthcare organizations. 

A CCM vendor should offer you the following:

Patient engagement

  • Assistance in identifying and enrolling eligible patients into the CCM program
  • Patient education about the benefits and services provided by CCM
  • Regular check-in calls or messages to ensure patient engagement
  • Resources for patient self-management and education about their conditions

Care planning

  • Development and regular updates of personalized care plans based on the patient's health status, preferences, and goals
  • Periodic assessment of patients to monitor the progression of chronic conditions and adjust care plans as needed

Medication and referrals

  • Assistance in  medication adherence and prescription refills
  • Manage referrals and ensure follow-up care

Operational efficiency

  • Assistance with billing for maximized revenue and compliance with any relevant regulations
  • Integration with Electronic Health Records (EHR)
  • Care coordination between different providers

Support and training

  • Provide training for healthcare staff on the CCM platform and processes
  • Offer ongoing provider support

Regulatory adherence

  • Ensure all services and technology solutions are compliant with local healthcare regulations, including data privacy and security standards

CCM software vs. full-service CCM programs

Some CCM vendors only offer software solutions, while others provide a full-service offering that includes technology and clinical services. While both CCM software and full-service CCM programs aim to improve the care of patients with chronic conditions, the software approach is more of a DIY tool for healthcare providers, giving you the tech resources needed. 

In contrast, a full-service CCM program offers a more hands-on, comprehensive solution, blending technology with a range of services to offload much of the day-to-day management and coordination tasks from the healthcare provider.

A full-service CCM program offers a more comprehensive approach to chronic care management than standalone CCM software. While both provide essential technological tools for managing patient care, a full-service program goes beyond software by incorporating dedicated care teams, 24/7 patient support, direct care coordination, and administrative support for billing and training. 

The integrated approach of a full-service CCM program alleviates much of the operational burden on healthcare providers. It ensures more proactive, consistent, and coordinated patient care, improving health outcomes and enhancing patient-provider relationships.

Elevate your CCM program with ChartSpan 

ChartSpan is not just another CCM provider; we partner with healthcare practices to deliver high-quality, patient-centered care. We ensure every chronically ill patient receives support in managing their conditions and feels valued throughout their healthcare journey.

We are committed to helping your practice improve patient outcomes. Regular check-ins and open lines of communication with a dedicated care team keep patients educated, informed, and active participants in their healthcare journey. 

Chronic Care Management with ChartSpan benefits your practice by providing an additional revenue stream without increasing your workload. Our CCM program helps you identify and close gaps in care to enhance your quality scores for better patient outcomes and increased Medicare reimbursements.

ChartSpan’s comprehensive and compassionate approach to CCM allows your practice to deliver top-tier chronic care. Talk with an expert to learn how we can help your practice stand out with patient-centric Chronic Care Management, or explore all of our preventive care solutions. 

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