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What Conditions Qualify for Chronic Care Management?

Chronic Care Management is a program that helps Medicare patients learn more about their chronic conditions and how they can manage them. Through CCM, patients are matched with a care coordinator who checks in every month to help them set health goals, schedule appointments with their provider, refill medications, and find community resources. But because some practices have never participated in Chronic Care Management, they may not be aware of all the conditions that qualify a patient for the program. 

Below, you’ll find a list of chronic conditions to help you determine whether you serve patients who might be eligible for CCM—and more details about how CCM can help those patients improve their health outcomes and take ownership of their chronic conditions.

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 that are expected to exist for at least 12 months and that put them at risk for exacerbation or functional decline. 

We've listed some of the most common qualifying conditions we encounter among patients below. Though these are conditions that often qualify patients for CCM, it is ultimately the provider who makes the clinical determination of which patients need CCM. 

Cardiovascular and Blood Conditions

Cardiovascular conditions that qualify patients for CCM include, but are not limited to: 

• Hypertension
• Ischemic heart disease
• Congestive heart failure
• Anemia
• Atrial fibrillation
• Hyperlipidemia
• Diabetes
• Coronary artery disease
• Sick sinus syndrome
• Angina
• Sickle-cell disease
• Peripheral vascular disease (PVD)

Cancer and Oncology Conditions

Various chronic cancers qualify for CCM, including:

• Breast cancer
• Lung cancer
• Prostate cancer
• Colorectal cancer
• Leukemias and lymphomas

Bone, Joint or Muscle Conditions

Bone, joint and muscle conditions that affect a person's quality of life can qualify for CCM. Examples are: 

• Osteoporosis
• Rheumatoid arthritis/osteoarthritis

Eye Conditions

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

• Cataracts
• Glaucoma
• Diabetic retinopathy
• Age-related macular degeneration

Additional Chronic Conditions that Qualify for CCM

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

Urology and Nephrology Conditions

Conditions that affect the bladder and kidneys include:

• Chronic kidney disease
• Benign prostatic hyperplasia 
• Kidney cysts

Gastroenterological Conditions

Some of the gastroenterological conditions that qualify for CCM are:

• Irritable bowel syndrome
• Crohn’s disease
• Ulcerative colitis

Ear, Nose, and Throat Conditions

A variety of ENT conditions can benefit from CCM:

• Sleep apnea
• Tinnitus
• Vertigo
• Conductive or sensorineural hearing loss

Mental Health and Neurological Conditions 

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

• ADHD
• Alzheimer’s Disease and dementia
• Post-traumatic stress disorder (PTSD)
• Anxiety disorders
• Depressive disorders
• Autism 
• Schizophrenia and other psychotic disorders
• Bipolar disorder 
• Traumatic brain injury and nonpsychotic mental disorders due to brain damage
• Migraine and chronic headaches
• Cerebral palsy
• Epilepsy
• Parkinson’s

Learn more: How to Manage Chronic Mental Illness with Chronic Care Management

Respiratory Conditions

Respiratory or lung conditions that Medicare patients might face include:

• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Emphysema
• Cystic fibrosis

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 dependence disorders 
• Opioid dependence disorders
• Nicotine dependence
• 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
• Hypothyroidism

Bone, Joint, Spine or Muscle Conditions

These conditions affect the nervous system or bones, muscles and joints. Examples are: 

• Spinal cord injury
• Spina bifida
• Muscular dystrophy
• Fibromyalgia
• Chronic pain

Other Disabling Conditions 

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

• Developmental and learning disabilities
• Intellectual disabilities and related conditions
• Liver disease, cirrhosis and other liver conditions
• Blindness and visual impairment
• Meniere’s disease and other sources of hearing loss
• Obesity

When practices sign up for CCM through ChartSpan, we compile a list of all patients that are eligible for CCM, according to CMS guidelines. The practice’s providers then review the list to see which patients they agree would be a good fit for the program. 

What Happens When Patients Are Eligible for CCM?

When a patient is eligible for CCM, they’ll be told about the program and asked if they want to enroll. If they choose to do so, they’ll receive at least 20 minutes of care coordination from a care manager each month, under the general supervision of a qualified provider. 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.

Their care coordinator will help them create  a comprehensive care plan that the patient can view at any time. Every month, the care coordinator will reach out to the patient to follow up on their care goals, perform care gap assessments, and help with scheduling appointments or refilling prescriptions. They can also provide resources for food, housing, social activities, and emotional support. 

Explore Chronic Care Management to Manage Your Patients’ Conditions

Using the chronic conditions list provided by CMS and assistance from an organization like ChartSpan, your practice can determine whether or not your patients qualify for a CCM program. Many conditions fall under this program, and ChartSpan's Chronic Care Management can ensure your eligible patients are continuously identified, informed about the program, and given the option to enroll. 
CCM programs like ChartSpan allow your staff to focus on in-person care while we manage administrative tasks and offer remote care for your CCM patients. If you would like to learn more, view our guide to frequently asked questions about CCM and compliance.