Chronic Care Management (CCM) extends care beyond the exam room. More than a billing code, CCM is a powerful tool that supports providers in the shift from volume to value. These services help fill the gaps between office visits, building stronger patient relationships and improved health outcomes.
What is Chronic Care Management?
CCM is a Medicare Part B benefit designed for patients with two or more chronic conditions expected to last at least 12 months – or until death – that place them at significant risk of decline or death. These patients often have multiple providers and a myriad of medications, creating opportunities for miscommunication and gaps in care. CCM addresses these challenges by providing consistent and proactive care management.
How Does CCM Work?
CCM services focus on non-face-to-face care. The Centers for Medicare and Medicaid Services (CMS) pays for CCM services provided to patients with multiple chronic conditions under the Medicare Physician Fee Schedule (PFS). Each month, patients receiving CCM support receive at least 20 minutes of care coordination, tailored to their unique needs. This includes:
- Recording and maintaining up-to-date health information
- Developing and updating a comprehensive care plan
- Monitoring care transitions
- Coordinating care across multiple providers
- Educating patients on how to manage their conditions effectively
A Better Patient Experience
Patients enrolled in Chronic Care Management benefit from a continuous relationship with a member of their care team. They have greater access to health information, regular check-ins to help them reach their health goals, and reminders for preventive services. This high-touch approach helps manage chronic conditions and prevent complications.
CCM also supports patients in:
- Managing medications safely and effectively
- Getting timely preventive care
- Connecting with community-based services
- Addressing psychosocial concerns
- Documenting and responding to functional decline
A Better Provider Experience
By actively engaging patients between visits, providers can identify and address issues early, reducing avoidable hospitalizations and improving overall clinical outcomes. This consistent relationship also encourages a stronger patient-doctor relationship, leading to better adherence and satisfaction. From a financial perspective, CCM creates new revenue streams through Medicare reimbursements while also contributing to shared savings in risk-based contracts. When scaled effectively, CCM services improve operational efficiency, contribute to better financial performance, and boost health outcomes.
Chronic Care Management makes a real difference. Let your practice lead the way in delivering smarter, more connected care.
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