Chronic Care
Management
powered by AI

Chronic care management (CCM) is a remote touchpoint in between visits for patients with 2 or more chronic conditions. This includes at least 20 minutes of care management throughout the month. A dedicated care partner communicates via phone or text to coordinate care and help with patient requests.

Comprehensive chronic care management benefits patients with 24/7 access to physicians and clinical staff who can meet their urgent and ongoing needs. CCM also benefits practices by electronically capturing all patient interactions for real-time continuity of care.

According to The Centers for Medicare & Medicaid Services (CMS), a comprehensive chronic care management plan typically includes but isn’t limited to: an expected outcome and prognosis, measurable treatment goals, cognitive and functional assessments, and symptom and medication management.

Before CCM services can start, CMS requires written or verbal patient consent, as well as an initiating visit for new patients or patients the billing practitioner hasn’t seen within 1 year. CCM services aren’t typically face-to-face and allow practices to bill at least 20 minutes or more of care coordination per month.

Eligible CCM patients must have 2 or more chronic conditions expected to last at least 12 months and place them at significant risk of death or functional decline. Conditions that qualify for chronic care management include, but aren’t limited to: Alzheimer’s disease, arthritis, asthma, cancer, cardiovascular disease, diabetes, and hypertension.

To receive CCM services, patients must have 2 or more chronic conditions expected to last at least 12 months or until their death.

For 500 enrolled patients, Medsien’s CCM solution can guarantee $250,000+ in additional annual revenue. With our accurate, automated billing and coding, we achieve an average monthly reimbursement rate of 98%.

Applicable CPT codes for chronic care management services include 99437, 99439, 99487, 99489, 99490, and 99491. You cannot report complex CCM and non-complex CCM for the same patient in a calendar month, and time counted toward the CCM service code cannot be counted for any other billed code. Refer to CMS.gov for the latest updates.

Medsien’s CCM solution makes it easy to deploy a chronic care management program in as fast as just a few days. Reach out to our team of CCM experts today to get started.

Inconsistent program management can result in annual losses of 25-50%, but practices that partner with Medsien achieve an average annual patient retention rate of 95%. Request a demo to learn how Medsien seamlessly handles patient enrollment.