Frequently asked questions about Chronic Care Management

CCM, or Chronic Care Management, is the name for care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient. These chronic conditions place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline.

These services are generally conducted remotely, by telephone, and allow your FQHC, Primary Care, or Value-Based Care office to bill for at least 20 minutes or more of care coordination services per month.

CCM is a preventative service, helping your eligible Medicare patients take a proactive approach to their health and wellness through regular, remote encounters with their care team.

Physicians and certain other health care professionals can bill for CCM services, including physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives.

Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals can also bill for CCM services.

Only one practitioner per patient may be paid for CCM services for a given calendar month.

A CCM program can provide help for patients with at least two chronic conditions, which are expected to last at least 12 months. Patients must consent to be in the program and each patient will require a care plan. Encounters must last at least 20 minutes each month in order to qualify for reimbursement.

Whether in-house or outsourced, a CCM program must be staffed by qualified, licensed clinicians to conduct your monthly patient encounters. While the path to success varies by clinic, there are four common steps to take toward establishing a CCM program:

  • Identify patients who qualify and make the connection.
  • Enroll interested patients.
  • Provide monthly phone calls for each enrollee from a dedicated representative who understands their current medical challenges.
  • Integrate patient assessments from each call directly into your EMR system to give updated health information and context to all in-person appointments.

Many providers want to support their vulnerable patients through a CCM program but cannot afford the additional capital and staffing required to begin. This is where an outsourced provider, like H3C, can help. With H3C, there are no start-up costs. You simply pay H3C a portion of your reimbursements from Medicare and private insurance, once your CCM program is running.

For additional resources when weighing in-house vs. outsourced CCM services, use this guide.

Read our full article that discusses the differences between Chronic Care Management and Case Management. Find it here.

Chronic Care Management CPT codes for your clinic’s billing could include:

  • G0511 – Federally qualified health center (FQHC) or Rural health center (RHC) CCM encounter
  • 99490 – Primary care provider, initial 30 minute CCM encounter
  • 99439 – Primary care, subsequent 20 minutes of care
  • 99487 – Cumulative 60 minutes of care
  • 99489 – Every additional 30 minute consultation, not in-person

For detailed information about when and how to use each code, consult this guide.

Chronic care management programs are designed to serve patients with two or more chronic conditions. Chronic is defined as, “expected to last at least 12 months or until the death of the patient.” Conditions vary, but all must reasonably place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline. This can encompass a host of physical and mental health diagnoses, the most common of which are:

  • Alzheimer’s disease
  • Arthritis
  • Asthma
  • Autism
  • Blindness
  • Cancer
  • Cardiovascular disease
  • Deafness or hearing impairment
  • Diabetes
  • Endometriosis
  • Epilepsy
  • Fibromyalgia
  • Heart disease
  • High blood pressure
  • HIV / AIDS
  • Hypertension
  • Migraines
  • Obesity
  • Psoriasis
  • Sickle Cell Anemia
  • Sleep apnea
  • Thyroid disease
  • Tuberculosis

Not sure if your patient population qualifies? Speak to an expert for a custom patient population assessment.

Chronic care management programs improve the health outcomes for your most vulnerable patients and open up a new revenue stream for your clinic at the same time.

Chronic care management encounters increase medication & care plan compliance in vulnerable populations. Patients engaged in chronic care management experience fewer hospitalizations. Finally, patients engaged in chronic care management feel connected to their healthcare staff and report increased satisfaction with their doctors and care teams.

The National Center for Biotechnology Information (NCBI) reports that patient-centered care programs like CCM have been correlated with reduced pain and discomfort, faster physical and emotional recovery, as well as improved outcomes and quality of life.

Your clinic and staff benefit, too. Outsourcing your CCM program with H3C results in risk-free new revenue for your clinic. Most clinics reinvest that new revenue into additional doctors and support staff, new and replacement equipment, and professional development for doctors, nurses, and staff. This all results in happier staff and better patient care.

Calculate the revenue your clinic could earn using our calculator.

H3C supports the documentation of your CCM encounters in a few ways:

  • We integrate patient assessments from each call directly into your existing EMR system in real-time.
  • Our team provides risk stratification reporting that will provide you with a monthly snapshot of your Medicare population and identify patients at risk.
  • Our team generates and uploads care plans to your EMR, and we mail those to your patients.
  • H3C compiles your monthly billing reports with all the information your clinic needs. In fact, a single staff member can submit your CCM billing in 30 minutes per month.

H3C collaborates with your clinic’s single point of contact to ensure that our calls match your clinic’s workflows and collect system-specific information critical to understanding your patients and community.

When we see patients showing declines, slippage, or issues, we flag the case for review by an H3C nurse supervisor. All changes are passed along to the designated champion.

After a baseline is established, we develop a customized care plan for each patient and our encounter calls check in on that plan each month.

At H3C, each of your patients receives a dedicated care team that will get to know them by name. Our encounter calls gather important information without sounding (or being) scripted.

H3C compiles your monthly billing reports with all the information your clinic needs. In fact, a single staff member can submit your CCM billing in about 30 minutes per month, no matter the size of your enrolled population.

H3C takes pride in adding value for your patients, not adding work for your clinical staff.

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