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Chronic Care Management

ChronicCare serves providers by offering chronic care management (CCM) services to their patients in order to improve health outcomes, and quality of life while enabling practices to generate revenue without increasing staff workload.  


2/3 of Medicare patients are eligible, which means many of your patients can benefit from our CCM services.

CCM is the care coordination that is outside of the regular office visit for patients with multiple (2 or more) chronic conditions that are expect to last at least 12 months

Your patients benefit by receiving monthly follow-ups to reinforce a comprehensive care plan. This leads to higher patient engagement and improved health outcomes.

Medicare reimburses providers for offering CCM to their patients. Our company lightens the load for your staff by offering CCM to your patients, your practice gets reimbursed.


Identify Eligible Patients

Patients who are eligible for chronic care management will have multiple (2 or more) chronic conditions expected to last at least 12 months or until the patient's death. These conditions must place the patient at significant risk of death, acute exacerbation and or decompensation, or functional decline. 

Examples include but are not limited to: Alzheimer's, dementia, arthritis, asthma, atrial fibrilation, autism, cancer, cardiovascular disease, COPD, depression, diabetes, hypertension, infectious diseases like HIV and AIDS.

Obtain Patient Consent

Get the patient's written or verbal consent for CCM services before starting CCM. This helps ensure patients are aware and approve of the monthly service. Patients can give consent digitally, verbally, or while at the practice. Patients have the right to stop CCM services at any time. Only 1 practitioner can furnish and bill CCM services during a calendar month.  


Develop Comprehensive Care Plan

Develop a comprehensive, person-centered, electronic care plan based on the patient's medical, functional, and psychosocial needs. The plan will help support disease control and health management goals, including physical, mental, cognitive, psychosocial, functional, and environmental factors. Patients may also receive a list of suggested resources and community services. 

Monthly CCM for at least 20 Minutes 

Our care managers provide patients with care management services once monthly for at least 20 minutes. This includes helping beneficiaries manage their medications, performing a structured clinical summary, providing patient education, and documenting patient interactions. 


Provider Billing for Reimbursement

Time spent providing these services will be tracked and shared with provider in order to bill Medicare. Our platform collects records of calls and other interactions, connects them to the appropriate patients, and then generates a single billing report. Our company does the work, and the provider generates additional revenue streams. 

CPT Codes for Chronic Care Management

CPT Code 99490

This is a 20-minute timed service provided by clinical staff or other health care professional to coordinate care across providers and support patient accountability. 

Reimbursement: $61.5

CPT Code 99439

Each additional 20 minutes of staff time spend for the patient (Billed in conjunction with CPT Code 99490).

Reimbursement: $47.2

CPT Code 99487

This is a 60-minute timed service provided by clinical staff or other health care professional for complex cases to coordinate care across providers and support patient accountability. 

Reimbursement: $131.9

CPT Code 99489

Subsequent complex CCM services for additional 30 minutes of care performed by clinical staff or other qualified health care professional. 

Reimbursement: $71.1

" - Payments vary with subject to specific locations - Please refer to

Frequently Asked Questions

+ Why Should a Healthcare Practice Have a CCM Program? There are three major reasons why a CCM program can be a game-changer for a healthcare practice. These include: Improved Patient Health: The most important reason to add a CCM program to any medical practice is to improve clinical outcomes for patients with chronic diseases. Reduced Staff Workloads: Another critical aspect is decreased workload on administrative staff. These days, more than 80% of the communications between a patient and their healthcare provider happen over phone calls. Increased Revenue Streams: Patient phone calls are usually non-billable and can take up a lot of precious time at a doctor’s office. With trained care coordinators handling such calls, the clinic/practice can focus on more productive tasks, handling patients who are physically present at the premises.

+ Is CCM suitable for all patients? CCM is specifically designed for individuals with chronic conditions such as diabetes, hypertension, heart disease, and more. It is most effective for patients that require ongoing care cand monitoring. Healthcare professionals assess each patient's needs to determine the suitability of CCM for their unique health situation.

+ How does CCM benefit patients? CCM enhances the quality of care for patients with chronic conditions by providing continuous support and coordination. It involves regular communication with healthcare providers, medication management, and personalized care plans, leading to better disease management and improved patient outcomes.

+ Is CCM secure and compliant with privacy regulations? Our CCM platform prioritizes patient privacy and complies with relevant healthcare data protection regulations. Robust security measures are in place to safeguard patient information, ensuring confidentiality and adherence to privacy standards. In addition, we are also HIPAA and SOC2 compliant.

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