What Conditions Qualify for Chronic Care Management?

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Chronic Care Management is a program that helps patients learn more about their chronic conditions and how they can manage them through a comprehensive treatment plan set forth by their physician. The goal of this preventative program is to improve patient health and help practices provide patients with quality treatment to manage their chronic conditions and improve their well-being.

Below, we provide a Chronic Care Management list of chronic conditions to help patients and health care providers determine eligibility. Continue reading to learn how ChartSpan’s solutions can help clinics and physicians manage patients eligible for Chronic Care Management. 

Qualifying CCM Chronic Diseases 

To qualify for a Chronic Care Management (CCM) program provided by Medicare, patients must have a minimum of two chronic conditions. We’ve listed some of the significant qualifying conditions provided by the Centers for Medicare & Medicaid Services (CMS) below, though it is not comprehensive. You can encourage patients who do not see their condition listed to contact their provider to see if they qualify. 

Cardiovascular and Blood Conditions

Conditions that damage the heart or contribute to cardiovascular conditions include:

  • Hypertension
  • Ischemic heart disease
  • Heart failure
  • Stroke/transient ischemic attack
  • Acute myocardial infarction
  • Anemia
  • Atrial fibrillation
  • Hyperlipidemia

Respiratory Conditions

Respiratory or lung conditions that qualify include:

  • Asthma
  • Chronic obstructive pulmonary disease (COPD)

Neurological and Mental Health Conditions

Brain and mental health conditions that qualify for CCM include:

  • Alzheimer’s disease 
  • Alzheimer’s disease, related disorders or dementia 
  • Depression

Cancer Conditions

Various cancers qualify for CCM, including:

  • Breast cancer
  • Lung cancer
  • Prostate cancer
  • Colorectal cancer
  • Endometrial cancer

Bone, Joint or Muscle Conditions

Bone, joint and muscle conditions that affect a person’s quality of life can qualify for CCM, such as:

  • Osteoporosis
  • Rheumatoid arthritis/osteoarthritis
  • Hip/pelvic fracture

Eye Conditions

Conditions that affect a person’s vision can also qualify for CCM, which include:

  • Cataract
  • Glaucoma

Additional CMS Chronic Conditions

Other conditions that affect various parts of the body and qualify for CCM include:

  • Acquired hypothyroidism 
  • Chronic kidney disease
  • Benign prostatic hyperplasia 
  • Diabetes

Other Qualifying Conditions

Other chronic or otherwise disabling conditions can qualify patients for the Medicare CCM program. The following is a list of other CCM conditions that could potentially qualify but are determined on a case-by-case basis:

Mental Health and Neurological Conditions 

Neurological and mental health conditions encompass a broad spectrum of disorders, which include:

  • ADHD, conduct disorders and hyperkinetic syndrome
  • Personality disorders
  • Post-traumatic stress disorder (PTSD)
  • Anxiety disorders
  • Depressive disorders
  • Autism spectrum disorders
  • Schizophrenia and other psychotic disorders
  • Bipolar disorder 
  • Traumatic brain injury and nonpsychotic mental disorders due to brain damage
  • Migraine and chronic headache
  • Cerebral palsy
  • Epilepsy

Substance Use Disorders

A person who becomes dependent on a substance can develop a substance use disorder. Those that can potentially qualify for CCM include:

  • Alcohol use disorders 
  • Opioid use disorder
  • Tobacco use
  • Other drug use disorders

Autoimmune Conditions

Conditions that damage a person’s immune system and ability to recover from injury or illness can potentially qualify for the CCM program. These conditions include:

  • Human immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV/AIDS)
  • Viral hepatitis
  • Multiple sclerosis and transverse myelitis

Blood Conditions

Blood conditions and blood cancers that could qualify for the CCM program include:

  • Sickle cell disease
  • Leukemias and lymphomas
  • Peripheral vascular disease (PVD)

Bone, Joint, Spine or Muscle Conditions

These conditions include anything that affects the nervous system or bones, muscles and joints, such as:

  • Spinal cord injury
  • Spina bifida and other congenital anomalies of the nervous system
  • Muscular dystrophy
  • Pressure and chronic ulcers
  • Fibromyalgia, chronic pain and fatigue 

Organ-Related Conditions

These conditions can impact one or multiple organs and include:

  • Liver disease, cirrhosis and other liver conditions
  • Cystic fibrosis and other metabolic developmental disorders 

Other Disabling Conditions 

Other conditions are disabling and can impact essential functions, meaning they could qualify for CCM. These conditions include:

  • Learning disabilities and other developmental delays
  • Intellectual disabilities and related conditions
  • Blindness and visual impairment
  • Deafness and hearing impairment
  • Mobility impairments
  • Obesity

When Are Patients Eligible for CCM?

For patients to be eligible for CCM, they must meet specific criteria, which includes:

  • Having two or more conditions that are expected to exist for at least 12 months or until the patient’s passing
  • Having two or more conditions that could put the patient at risk for death, exacerbation, decompensation or functional decline

CCM also requires the creation of a comprehensive care plan that’s established, monitored, implemented and available to the patient. The CCM eligibility criteria help eliminate ethnic and racial disparities in the healthcare industry. 

When patients enroll in CCM, they’ll receive at least 20 minutes of care coordination each month, often under general supervision of a qualified physician. These 20 minutes usually aren’t face-to-face unless there’s a need for an in-office visit regarding CCM services. Patients will also have around-the-clock access to a care team member if an urgent medical need arises. 

Give Your Patients the Best Care With a Fully Managed CCM Program

ChartSpan helps patients get access to the proper care for their chronic conditions. We assist practices and hospitals with finding eligible patients, gaining their consent, improving their health through consistent care, and generating a new stream of revenue while doing so. 

Our Chronic Care Management Program helps medical practice staff have more time to focus on their patients and facilitate their care. We assist all practice types including Rural Health Clinics (RHC) or Federally Qualified Health Clinics (FQHC) through our CCM program solutions, supporting your providers by handling outreach, enrollment, follow-ups and additional small administrative tasks. Our complete services for patients include:

  • 24/7 access to care through our nurse line
  • Support resources to address Social Determinants of Health
  • Prescription refill assistance
  • Appointment scheduling assistance
  • Imaging, labwork and test result assistance

These are just a few of the many patient-based solutions we offer to help clinics provide adequate care to their patients. We can help identify gaps in care and provide data to help you exceed your quality care measurements.

Trust ChartSpan as Your CCM Patient Program Solution

Using the chronic conditions list provided by CMS, your organization can determine whether or not your patients qualify for a CCM program. Many conditions fall under this program, and ChartSpan’s Chronic Care Management Program can ensure your eligible patients are continuously identified, informed, and consented to the program. Our highly qualified team members will reach out to your patients monthly to ensure they get the support and attention they need.

Our program allows your staff to focus on in-person care while we take care of administrative tasks for your CCM patients. We’ll help improve patient outcomes and quality scores and introduce a new monthly revenue stream to your organization. Contact ChartSpan today for a demo!

Published: September 14, 2022

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