The idea of adding another program to your practice’s workflow can feel overwhelming. Your team is already stretched thin, and the last thing you need is more administrative complexity. But what if a program could actually streamline your work while improving care? A well-designed Chronic Care Management (CCM) program does just that. By creating a structured system for non-face-to-face care, you can manage your most complex patients more efficiently, prevent emergencies before they happen, and reduce the burden on your in-office staff. It’s a way to provide a higher level of proactive care without adding to the chaos.
Key takeaways
- Improve patient health while growing your practice: A CCM program provides the proactive support that reduces hospitalizations and improves quality of life for patients, all while generating a new, reliable revenue stream for your practice.
- Build a compliant program from the ground up: Success depends on a solid operational foundation, including meticulous EHR documentation, the right technology for care coordination, and strict adherence to Medicare guidelines to ensure reimbursement.
- Prioritize patient engagement for long-term success: A program's value is tied to patient retention, so use clear communication protocols, ongoing education, and personalized support to build trust and keep patients actively involved in their care.
What is a Chronic Care Management (CCM) program?
Think of a Chronic Care Management (CCM) program as a partnership between your practice and your patients who are living with multiple chronic conditions. It’s a structured way to provide continuous care and support outside of regular office visits. At its heart, CCM is a Medicare initiative designed to help patients proactively manage their long-term health conditions. Instead of only addressing problems when they flare up, CCM focuses on consistent, non-face-to-face support to keep patients stable and healthy at home.
This approach helps you manage everything from medication adherence to coordinating with specialists, all while keeping the patient actively involved in their own health journey. It’s about creating a system of care that extends beyond the four walls of your clinic, offering patients the guidance and resources they need, right when they need them. For small and mid-size practices, launching a CCM program is a powerful way to improve patient outcomes, build stronger patient relationships, and create a new, reliable revenue stream without adding significant administrative work for your in-office staff.
The core components of a CCM program
Every successful CCM program is built around a comprehensive, personalized care plan. This isn't just a document; it's a roadmap for the patient's health. According to Medicare guidelines, this plan should be created within your EHR and a copy provided to the patient. It typically includes a detailed list of the patient's health problems and goals, all current medications, a directory of their other healthcare providers, and information on necessary community services. This living document serves as the single source of truth for the patient's entire care team, ensuring everyone is aligned and working toward the same objectives.
How a CCM program works in practice
Most CCM services occur between appointments, a key feature that makes the program so effective. Instead of waiting for the next scheduled visit, your care team can connect with patients via phone, secure messaging, and other remote check-ins. A critical requirement is that patients must have 24/7 access to a member of the care team for any urgent needs. This continuous line of communication helps address minor issues before they become major health events, providing patients with peace of mind and immediate support when they feel uncertain or concerned about their health.
The central role of care coordination
Patients with multiple chronic conditions often see several different specialists, which can lead to fragmented care. CCM acts as the central hub for all communication, ensuring seamless care coordination. Your team can help schedule appointments, share notes between providers, and manage transitions between care settings, like from a hospital stay back to home. This oversight is crucial for preventing dangerous drug interactions, avoiding redundant tests, and making sure the patient’s comprehensive care plan is followed by everyone involved. It transforms care from a series of separate interactions into one cohesive, patient-centered strategy.
Which patients qualify for a CCM program?
Before you can launch a successful CCM program, you need to know which patients are the right fit. Identifying eligible patients is the foundation for delivering care and getting reimbursed. The criteria are specific but straightforward. Qualification comes down to three key areas: meeting Medicare's rules, having specific health conditions, and getting the patient's go-ahead. Let's walk through each one so you can confidently build your patient list.
1. Meeting Medicare's eligibility requirements
Medicare sets the baseline for who qualifies for CCM services. The main rule is that a patient must have two or more chronic conditions expected to last at least 12 months. These conditions must also place the patient at significant risk of functional decline or worse. Think of a patient managing both advanced arthritis and diabetes. This requirement ensures the program focuses on patients who truly need coordinated, ongoing support. You can find the official guidelines on Medicare's CCM coverage page, which is a great resource to keep handy for your team.
2. Common qualifying health conditions
While the "two or more" rule is the starting point, it helps to know which conditions typically qualify. The list is long, but some of the most common ones include hypertension, heart disease, diabetes, chronic kidney disease (CKD), COPD, and depression. The key is that these conditions, in combination, create a complex health situation requiring ongoing management. A CCM program is designed for these patients, providing the structured support they need to stay on track with treatment and avoid complications that could lead to hospital visits.
3. Securing patient consent
A patient can’t be enrolled in a CCM program without their permission. This is a critical step for both compliance and patient engagement. You must obtain and document their consent—which can be verbal or written—before providing any services. This conversation is the perfect time to explain how the program works and what they can expect. After getting their approval, you’ll create a comprehensive, personalized care plan. It’s essential to provide a copy of this plan to the patient, as it acts as a roadmap for their care and reinforces their active role in managing their health.
What services should a CCM program include?
A successful CCM program is much more than a monthly phone call. It’s a structured set of services designed to provide continuous, proactive care for your patients with multiple chronic conditions. Think of it as a safety net that operates between office visits, helping patients manage their health at home while keeping your practice connected to their daily progress. This consistent support helps prevent complications, reduce hospitalizations, and empower patients to take a more active role in their well-being. For your practice, it means extending your care beyond the clinic walls without adding an unmanageable burden to your in-house staff.
The Centers for Medicare & Medicaid Services (CMS) outlines specific service requirements for a billable CCM program. These components work together to create a holistic care experience that addresses everything from daily medication questions to long-term health goals. By integrating these core services, your practice can deliver comprehensive support that not only improves patient outcomes but also strengthens the patient-provider relationship. It transforms your practice from a reactive service to a proactive partner in your patients' health. Below are the essential services every effective CCM program should offer to meet compliance standards and deliver real value.
Comprehensive care planning
The comprehensive care plan is the foundation of any CCM program. It’s a personalized roadmap that details a patient's health problems, treatment goals, medications, and care team members. This isn't a static document filed away after one visit; it's a dynamic plan that evolves with the patient's health. It should be developed collaboratively with the patient, reflecting their personal goals and preferences. This plan ensures everyone involved in the patient’s care—from specialists to community service providers—is on the same page, working toward the same objectives. It centralizes all critical health information, making care coordination seamless and effective.
Medication management
For patients with multiple chronic conditions, managing a long list of medications can be overwhelming and risky. A key service of CCM is dedicated medication management. This involves more than just refilling prescriptions. Your care team will perform medication reconciliation to prevent dangerous interactions, ensure the patient understands how and when to take each drug, and monitor for side effects. This hands-on approach helps improve medication adherence, which is critical for controlling chronic diseases like hypertension and diabetes. By reducing medication errors, you can directly prevent adverse events and unnecessary emergency room visits, keeping your patients safer at home.
24/7 access to a care team
Health issues don’t follow a 9-to-5 schedule. That’s why a core requirement of CCM is providing patients with 24/7 access to a member of the care team for urgent needs. This gives patients invaluable peace of mind, knowing they can get timely medical advice without having to resort to an ER visit for non-emergency issues. This continuous access ensures that urgent concerns are addressed promptly, preventing minor problems from escalating into major health crises. It also reinforces the patient's connection to your practice, showing them that you are a constant partner in their health journey.
Support during care transitions
Transitions between care settings—like being discharged from a hospital or moving to a skilled nursing facility—are incredibly vulnerable times for patients. CCM provides crucial support during these periods to ensure a safe and smooth handover. This service, often part of a broader transitional care management (TCM) strategy, helps coordinate post-discharge care, schedule follow-up appointments, and perform medication reconciliation. By managing these details, your care team can significantly reduce the risk of medication errors, missed appointments, and preventable hospital readmissions, ensuring continuity of care when it matters most.
Remote health monitoring
Integrating Remote Patient Monitoring (RPM) is a powerful way to enhance your CCM program. RPM uses connected devices like blood pressure cuffs, scales, and glucose meters to collect daily health data from patients at home. This information is sent directly to your care team, providing a real-time window into the patient's condition between appointments. This data allows for proactive interventions—if a patient's blood pressure spikes or their weight suddenly increases, your team can step in immediately. It’s an essential tool for managing conditions like heart failure, hypertension, and COPD, enabling you to catch issues before they become emergencies.
Patient education and resources
An empowered patient is a healthier patient. A vital component of CCM is providing ongoing education and resources to help patients better understand and manage their conditions. This involves teaching them self-management techniques, explaining the importance of their treatment plan, and providing information on diet, exercise, and lifestyle changes. When patients feel confident in their ability to manage their health, they are more likely to adhere to their care plan and make healthier choices. This educational support fosters independence and gives patients the tools they need to become active participants in their own care.
The benefits of a CCM program
Implementing a CCM program is one of the most impactful decisions you can make for your patients and your practice. It’s a true win-win, creating a framework for proactive, continuous care that improves patient health while also building a new, sustainable revenue stream. By dedicating resources to managing chronic conditions outside of traditional office visits, you can address patient needs more effectively, prevent costly complications, and strengthen the patient-provider relationship. Let's look at the specific advantages you can expect.
Improve patient outcomes
A well-structured CCM program directly contributes to better health for your patients. Instead of only seeing patients when a problem arises, you’re providing consistent, proactive support between appointments. This regular contact helps patients stay on track with their care plans, manage medications correctly, and make healthier lifestyle choices. Studies show that this kind of structured management leads to improved health outcomes for those with chronic conditions. By catching potential issues early and offering ongoing guidance, you can reduce hospital readmissions, prevent acute events, and give your patients a better quality of life.
Reduce overall healthcare costs
Chronic diseases are a massive driver of healthcare spending, costing the U.S. system trillions each year. A CCM program helps lower these costs by preventing expensive emergency room visits and hospitalizations. When patients have a dedicated care manager to call, they can get advice for minor issues before they escalate into major problems. This proactive approach also helps avoid complications like adverse drug interactions. By investing in preventative management through CCM, your practice plays a vital role in creating a more efficient and cost-effective healthcare system for everyone.
Increase patient engagement
When patients feel supported and heard, they become more active participants in their own care. CCM programs are built on a foundation of strong communication and trust, which is essential for patient engagement. Regular check-ins, access to a care team, and personalized education empower patients to understand their conditions and adhere to their treatment plans. This partnership leads to better self-management and more open conversations about their health goals and challenges. An engaged patient is more likely to follow medical advice, report new symptoms promptly, and ultimately achieve better results.
Generate new practice revenue
Beyond the clinical benefits, a CCM program offers a significant financial advantage for your practice. Recognizing the value of this proactive care, Medicare provides monthly reimbursement for CCM services. This creates a predictable, recurring revenue stream that can help your practice grow and invest in more patient resources. By billing for the non-face-to-face time your team already spends coordinating care, you can turn that essential work into a sustainable part of your business model. This allows you to provide a higher level of care without straining your practice’s finances.
Streamline care coordination
Patients with multiple chronic conditions often see several different specialists, which can lead to fragmented and confusing care. A CCM program acts as the central hub for all of a patient’s health information. Your care team ensures that everyone involved—from the cardiologist to the endocrinologist to the primary care physician—is on the same page. This comprehensive care coordination prevents conflicting treatments, reduces redundant tests, and creates a seamless experience for the patient. It ensures that nothing falls through the cracks, especially during transitions between care settings like a hospital and home.
The rules set by Medicare and other payers are specific, covering everything from patient consent to how you document your time. Getting these details right from the start prevents billing headaches and ensures your program is built to last.
Staying compliant: CCM program requirements
Launching a CCM program is an incredible way to support your patients and create a new, recurring revenue stream for your practice. But to make it successful and sustainable, you have to get the compliance piece right. Think of these requirements not as hurdles, but as the foundation for a high-quality, audit-proof program that truly serves your patients and protects your practice.
The rules set by Medicare and other payers are specific, covering everything from patient consent to how you document your time. Getting these details right from the start prevents billing headaches and ensures your program is built to last. It’s about creating a system that is both effective for patient care and financially sound. For busy practices, managing these details can feel overwhelming, which is why many choose to work with a partner who specializes in CCM compliance. This lets you focus on patient care, knowing the administrative and regulatory details are in expert hands.
Mastering documentation standards
Think of documentation as telling the story of your patient’s care. For every patient in your CCM program, every service you provide must be meticulously recorded in their electronic health record (EHR). This isn’t just about ticking a box; it’s essential for accurate billing, ensuring continuity of care, and passing any potential audits. Your documentation should include the comprehensive care plan, records of patient communication, time spent on non-face-to-face services, medication management, and any referrals. The American Academy of Family Physicians offers detailed guidance on what CCM documentation should include. Clear, consistent records are your best defense in an audit and a cornerstone of a well-run program.
Tracking key quality metrics
How do you know if your CCM program is actually working? By tracking the right metrics. Payers, especially Medicare, want to see that your services are leading to better health outcomes. This means you’ll need to monitor both process and outcome measures. Process measures look at how your program is running—things like how many patients are enrolled or how consistently you’re communicating with them. Outcome measures track the impact on patient health, such as reduced hospital readmissions, better blood pressure control, or improved A1c levels for patients with diabetes. Tracking these key evaluation measures proves the value of your program and helps you refine your approach over time.
Ensuring patient privacy and security
Trust is the bedrock of the provider-patient relationship, and that extends to your CCM program. Before enrolling a patient, you must get their explicit consent. This involves a clear conversation explaining what the CCM service entails, how it will help them manage their conditions, and that a monthly copay may apply. This verbal consent must be documented in the patient’s medical record. Beyond consent, all patient interactions and data must be handled with strict adherence to HIPAA rules. Since CCM involves phone calls, patient portals, and remote monitoring devices, ensuring the security of protected health information (PHI) is non-negotiable.
Following medicare guidelines
Medicare sets the standard for most CCM programs, so understanding their rules is critical. To be eligible, a patient must have two or more chronic conditions that are expected to last at least a year and place them at significant risk. Medicare’s CCM coverage rules also outline exactly what services can be billed, the minimum amount of time that must be spent on care coordination each month, and which members of your clinical staff are qualified to provide the services. Staying up-to-date on these guidelines is essential for reimbursement and ensures your program remains compliant. These rules are designed to ensure patients receive meaningful, consistent support between office visits.
Essential staff training
Your team is the engine of your CCM program, and proper training is the fuel. Everyone involved, from medical assistants to nurses, needs to understand the program’s workflows, documentation requirements, and the technology you’re using. They should be comfortable explaining the program to patients, documenting their time accurately, and using the EHR to manage care plans. This type of CCM requires a different rhythm of patient interaction than traditional office visits. Investing in training ensures your team can operate the program efficiently and effectively, which leads to better patient engagement, fewer billing errors, and a much smoother experience for everyone involved.
Choosing the right technology for CCM
The right technology is the engine that powers a successful CCM program. It’s what enables your team to coordinate care efficiently, engage with patients effectively, and stay compliant with all the rules. Without a solid tech foundation, even the best-laid plans can fall flat. Think of it as the central nervous system of your CCM services—connecting your staff, your patients, and critical health data in one seamless workflow. The goal is to find a solution that simplifies your processes, not one that adds another layer of complexity to your day. A great platform will feel like a natural extension of your practice, making it easier to deliver the high-touch care your chronic disease patients need.
Finding the right digital health platform
Your digital health platform is your home base for all things CCM. It’s the software you’ll use to manage patient care plans, track time, and communicate with your patients between visits. A good platform provides the framework to effectively manage and coordinate care for patients with multiple chronic conditions. When you’re evaluating options, look for a system that is intuitive for both your clinical staff and your patients. A clunky, hard-to-use interface can quickly lead to frustration and low adoption. Your ideal platform should support all the core components of CCM, from care planning to billing, in a single, unified system that feels easy to use from day one.
The importance of EHR integration
If a platform doesn’t integrate smoothly with your EHR, it’s a non-starter. Every CCM service—from medication adjustments to specialist referrals—must be documented in the patient's EHR. This is a firm requirement for compliance and reimbursement. A platform with deep EHR integration saves your team from the time-consuming and error-prone task of manual double-entry. It ensures that a complete, up-to-date record of all care activities is always available in the patient’s chart. This creates a single source of truth, which is essential for high-quality, coordinated care and for passing any potential payer audit. Seamless integration means less administrative work and more time focusing on patients.
Tools for patient communication
Consistent communication is the heart of CCM, and your technology needs to make it easy. Patients should be able to reach their care team easily, and vice-versa. While phone calls are still important, modern platforms should offer multiple ways to connect. Considering that two-way texting is preferred by 95% of patients, offering secure messaging is a great way to meet them where they are. Look for a platform that includes a suite of communication tools, such as secure messaging, video calls, and automated reminders, to keep patients engaged and connected to their care plan. The easier it is for patients to communicate, the more likely they are to stay active in managing their health.
Data analytics and reporting
How do you know if your CCM program is actually working? The answer is in the data. Your technology platform should make it simple to track progress and measure outcomes. Process measures, which focus on how your program is implemented, are key to understanding what’s working and where you can improve. Your platform should offer clear, easy-to-understand dashboards and reporting features. This allows you to monitor key metrics like patient engagement levels, staff time spent on CCM activities, and clinical outcomes. This data is invaluable for demonstrating the program's value to both patients and payers, and for making informed decisions to refine your services over time.
Security and HIPAA compliance
Protecting patient privacy isn’t just good practice—it’s the law. Any technology you use for CCM must be fully HIPAA compliant to safeguard protected health information (PHI). A data breach can be devastating for your patients and your practice, leading to heavy fines and a loss of trust. When choosing a technology partner, be sure to verify their security protocols. Providers must ensure that all patient data is handled in compliance with HIPAA regulations to protect patient privacy and security. Ask potential vendors about their data encryption, access controls, and audit trails to ensure they take security as seriously as you do. This is a non-negotiable for building a sustainable and trustworthy CCM program.
How a turnkey solution simplifies CCM for busy practices
Even the most well-designed CCM program can become overwhelming once it’s time to operationalize it. From identifying eligible patients and tracking monthly encounters to staying compliant with Medicare documentation rules, the administrative work can quickly outweigh the clinical benefits. For many small and midsize practices, the key to success lies in finding a turnkey CCM solution—one that handles both the technology and the day-to-day workflows.
A true turnkey solution combines the power of automation with expert human support. It integrates directly with your existing EHR, manages patient enrollment and outreach, and ensures every minute of care is properly tracked and billed. This structure allows your team to focus on patient care while the system quietly handles compliance, documentation, and reporting in the background.
1bios is one example of how this approach works in practice. The platform delivers a fully managed, Medicare-compliant CCM program that blends AI-powered automation with an experienced, U.S.-based care team. Every task—from patient identification to monthly follow-up—is logged automatically and aligned with CMS standards, giving your practice a simple, reliable way to provide continuous care without adding staff or complexity.
By choosing a turnkey solution, practices can turn the idea of CCM into a sustainable reality—launching faster, maintaining compliance with confidence, and giving patients the ongoing support they need between visits.
Effective patient engagement strategies
A CCM program is only as effective as the patients who participate in it. Keeping patients actively involved is the most critical factor for improving health outcomes and ensuring the long-term success of your program. True engagement isn’t just about checking boxes; it’s about building a trusting relationship that empowers patients to take control of their health. When patients feel supported and heard, they are more likely to adhere to their care plans and stay enrolled in your program. This creates a positive cycle of better health, stronger patient-provider relationships, and more consistent practice revenue.
Best practices for patient enrollment
The enrollment conversation is your first and best opportunity to set the tone for your entire CCM program. Go beyond simply explaining the service and obtaining consent. Use this time to connect with your patients, understand their personal health goals, and clearly articulate how the program will help them. Explain that CCM provides a dedicated care team member whom they can reach between appointments for support. Frame it as a partnership designed to help them stay on track with their treatment, manage symptoms, and feel more confident in their daily health decisions. A strong, positive start builds the foundation for lasting engagement.
Setting up clear communication protocols
Effective communication is the engine of any successful CCM program. While phone calls have their place, relying on them alone can create barriers for patients. Research shows that modern, convenient options are far more effective; in fact, 95% of patients prefer two-way texting for healthcare communication. By offering secure messaging, you make it easy for patients to ask quick questions, confirm appointments, or report a new symptom without the hassle of a phone call. Establishing these clear and accessible communication channels from the beginning ensures patients feel connected and supported, knowing that help is always just a quick message away. This approach respects their time and integrates care seamlessly into their lives.
Building patient education and support systems
Empowering patients with knowledge is a critical part of chronic care. When patients understand their conditions and the "why" behind their treatment plans, they are better equipped to manage their health effectively. Your program should include a system for providing ongoing education and support. This can involve sending easy-to-understand articles, short videos, or simple tips related to their specific conditions. The goal is to help patients improve self-management and feel more in control. By consistently providing valuable resources and encouragement, you transform your CCM program from a simple service into an indispensable support system that patients rely on.
How to improve patient retention
Patient churn is a significant challenge for many CCM programs. As one industry expert notes, managing enrollment is a "non-stop, daily operational requirement." Keeping patients engaged long-term requires a proactive and personalized approach. Don't wait for a problem to arise to reach out. Schedule regular, brief check-ins to see how they're doing and offer encouragement. Celebrate their progress, no matter how small. Personalize your communication by referencing their specific goals and challenges. This consistent, thoughtful interaction shows patients you are invested in their well-being, which builds loyalty and dramatically reduces the likelihood they will drop out of the program.
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A guide to CCM billing and reimbursement
Setting up a CCM program is a fantastic step toward better patient care, but making it financially sustainable is just as important. Getting the billing and reimbursement process right ensures your practice can continue offering these valuable services without straining your resources. It’s all about understanding the rules of the road so you can get paid accurately and on time for the work you’re doing. Think of it less as a chore and more as the engine that powers your program, allowing you to focus on what matters most: your patients.
Successfully billing for CCM comes down to a few key areas: using the right codes, understanding how payments are structured, keeping meticulous records, and knowing how to make the program a reliable source of revenue. It might seem like a lot at first, but once you have a solid system in place, it becomes a seamless part of your workflow. A well-managed billing process not only supports your practice’s bottom line but also reinforces the value of proactive, coordinated care for your patients with chronic conditions. Let’s walk through exactly what you need to know to handle CCM reimbursement with confidence, turning a potential administrative headache into a straightforward and profitable part of your practice.
Understanding Medicare billing codes
To get reimbursed for your CCM services, you need to speak Medicare’s language—and that means using the correct CPT codes. The primary CCM CPT codes are designed for patients who have two or more chronic conditions that are expected to last at least a year. The most common code is 99490, which covers the initial 20 minutes of clinical staff time each month. For more complex cases or additional time spent, you can use codes like 99487 and 99491. Using the right code ensures you’re accurately billing for the level of care and time your team dedicates to each patient every month.
Common payment models
CCM services are covered under Medicare Part B. This is great news for practices because it provides a clear and established pathway for reimbursement. After a patient meets their annual Part B deductible, Medicare typically covers 80% of the approved amount for CCM services. The remaining 20% is the patient's responsibility, which is often covered by supplemental insurance. This payment structure creates a predictable, recurring revenue stream for your practice while making continuous care more accessible and affordable for the patients who need it most.
Documentation for successful reimbursement
In the world of medical billing, if it wasn’t documented, it didn’t happen. Meticulous documentation is the key to successful reimbursement and staying audit-proof. Every CCM service must be logged in the patient’s EHR. This includes tracking time spent on care coordination, managing prescriptions and referrals, and all patient communications. You also need to create a comprehensive, personalized care plan and provide a copy to the patient. Consistent and thorough documentation in the patient's EHR creates a clear record of the value you’re providing and justifies every claim you submit.
How to maximize your revenue
A well-implemented CCM program is more than just a clinical initiative; it’s a smart business decision. By providing and billing for these services, you create a new, recurring revenue stream that can significantly strengthen your practice’s financial health. To maximize this revenue, it’s important to enroll all eligible patients and ensure your team is accurately tracking and documenting their time. Keep in mind that reimbursement rates can vary based on your location and practice type. Understanding your local payment landscape helps you forecast revenue and demonstrate the program's financial benefits to your practice.
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Frequently asked questions
How much time does my staff need to spend on CCM per patient each month?
To bill for the most common CCM code (99490), your clinical staff needs to provide at least 20 minutes of non-face-to-face care management services for a patient within a calendar month. This time can be spent on activities like coordinating with specialists, managing medications, or talking with the patient over the phone. It's important to have a reliable system for tracking this time accurately for each patient to ensure you meet the requirements for reimbursement.
Can my current medical assistants or nurses provide CCM services?
Yes, absolutely. Medicare allows licensed clinical staff, such as registered nurses, LPNs, and certified medical assistants, to perform and document CCM services under the general supervision of a physician or other qualified healthcare professional. This flexibility is a huge advantage for smaller practices, as it allows you to use your existing team to run the program without having to hire new staff specifically for this role.
How is billable CCM different from the care coordination we already provide?
While you're likely already doing some form of care coordination, a formal CCM program has specific requirements that make it a billable service. The key differences are the need for documented patient consent, the creation of a comprehensive care plan that is shared with the patient, and the meticulous tracking of at least 20 minutes of non-face-to-face care management time per month. It essentially formalizes and structures the great work you're already doing so you can be reimbursed for it.
Do we have to use special software, or can we just use our EHR?
While you can technically use your EHR to document time and manage care plans, it's often inefficient and not designed for the specific workflows of a CCM program. A dedicated platform built for CCM simplifies everything by automating time tracking, streamlining patient communication, and integrating with your EHR. This ensures all your documentation is compliant and audit-proof without creating a lot of manual work for your team.
What's the most important first step to launching a CCM program?
The best first step is to identify a small group of eligible patients to start with. Look for patients who have two or more chronic conditions and who you believe would truly benefit from the extra support. Starting with a pilot group allows your team to get comfortable with the workflows, documentation, and time-tracking process on a smaller scale before you roll the program out to all eligible patients in your practice.
