What is CCM?
Chronic Care Management (CCM) supports patients living with two or more chronic conditions like diabetes, hypertension, asthma, or heart disease. It provides continuous, coordinated care between regular clinic visits — keeping patients healthier, engaged, and informed.
Who is Eligible?
- Patients with 2+ chronic conditions
- Conditions expected to last 12+ months
- Enrolled in Medicare Part B
- At risk of functional decline or serious health events
Services Included
- Monthly follow-up calls from care team
- Custom care plans
- Medication reminders & adherence tracking
- Scheduling & follow-ups
- 24/7 nurse line
- Coordination across providers & specialists
Benefits for Providers
- CMS-reimbursable service (CPT 99490 & others)
- New monthly revenue stream
- No added burden on clinic staff
- Detailed care reports and documentation
- Boosts quality scores and patient retention
Benefits for Patients
- Regular guidance between appointments
- Help managing medications and symptoms
- Lower ER visits and hospitalizations
- Personalized support and easy access to care
- Better overall health outcomes