What is Chronic Care Management?

The Ins & Outs of Chronic Care Management

By Meghan Franklin

In 2015, Centers for Medicare and Medicaid Services (CMS) began paying separately under the Medicare physician fee schedule for chronic care management (CCM) provided to Medicare patients with two or more chronic conditions.

According to CMS, approximately one in four adults have two or more chronic health conditions—things like Alzheimer’s disease, autism spectrum disorders, certain types of cancers, depression, osteoporosis, HIV/AIDS and hypertension.

CMS’s decision to reimburse for CCM services reflects an industry-wide shift towards value-based care and the increasing value payers are assigning to proactive efforts to manage patients’ health.

So, what constitutes CCM?

CMS defines CCM as “care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

CMS’s CCM program allows for physicians, physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives to bill for at least 20 minutes or more of care coordination services per month. Only one practitioner can bill for CCM services per patient during any given month.

What might a patient participating in a CCM encounter?

CMS makes the patient an active participant in CCM; an important tenet of care coordination. A patient receiving CCM services must explicitly consent – either verbally or in writing– to receiving such services. Consent must be documented in the medical record, and, per CMS, the patient must be informed about: “the availability of CCM services and applicable cost-sharing, that only one practitioner can furnish and be paid for CCM services during a calendar month, and the right to stop CCM services at any time.”

So, first and foremost, patients must understand what CCM entails and agree to participate. Once they’ve elected to participate, the American Academy of Family Physicians says there are eight things that patients can expect while participating in CCM:

  • Round-the-Clock access to Care management Services. Patients must have a way to get in touch with healthcare providers in the practice to address urgent care needs, 24 hours a day, 7 days per week. This doesn’t mean that all practitioners must be available via phone at all times – it just means that the patient must be able to connect with someone who can help address their needs in a timely manner.
  • Care Continuity. This means patients must be able to see the same care team member for their routine appointments, allowing them a certain level of consistency and continuity of care.
  • Care Management. Explicit in its name, CCM includes active management of patients’ care, including ensuring patients receive all recommended preventive care services and providing oversight of patients’ medication management.
  • A Patient-Centered Care Plan. Patients can expect a care plan that’s tailored to their specific needs, choices and values. A patient-centered plan of care takes into account things like cognitive ability and environmental factors that may affect a patient’s ability to implement certain components of a care plan.
  • Help with Care Transitions. Transitions in care happen between care providers and between care settings – when a patient is discharged from an emergency department to home, for example. The CCM program prescribes that relevant patient information – in accordance with the clinical summary standard that is acceptable for that year’s electronic health record incentive program – must be communicated electronically when care transitions occur.
  • Care coordination with Home and Community-based Providers. Coordinating care with providers outside of a patient’s medical home helps to ensure a patient’s psychosocial needs are met so they can more effectively participate in their care plan.
  • Enhanced Communication. In addition to telephone communication, patients must have the opportunity to communicate with their provider through methods like secure messaging or other non-face-to-face methods.
  • Electronic Record and Availability of Care Plan. A patient’s care plan must be available at all times to all providers within a practice who are providing CCM services. The care plan must also be transmitted electronically, when needed, to other providers participating in the patient’s care plan.

What’s in CCM for healthcare practices, and what are some barriers to adoption?

In an article for Becker’s Hospital Review, Zachary Blunt says that healthcare practices can receive $42 or more per month per patient participating in CCM. Despite the financial incentive to adopt a CCM program, Blunt says it’s not being adopted as widely as CMS had anticipated. Blunt cites confusion about billing, fears that documentation will be time-intensive, and a general aversion to placing an additional administrative burden on staff as common barriers to CCM program adoption.

Blunt says that practices can overcome these barriers and start to reap the financial rewards of the CCM program by implementing five simple practices. He advises practices to:

  1. Create a Standard CCM Enrollment Workflow. Practices can set up their electronic health record to automatically flag patients as eligible for the CCM program and follow-up from there.
  2. Develop Repeatable Processes. Practices should understand what CCM requires in terms of patient interaction and outreach outside of office visits, and set up repeatable processes to make meeting those requirements as easy as possible.
  3. File CCM Reimbursement Claims Monthly.
  4. Regularly check in on the program. Practices should seek to regularly evaluate enrollment numbers and assess how their CCM program is providing value to patient-participants.
  5. Look for Commercial Payer Reimbursement Opportunities. Blunt notes that commercial payers will often reimburse for CCM-related activities at a 15 to 20 percent higher rate than Medicare.



Meghan Franklin is a freelance writer who has worked extensively in healthcare, both as a writer and as a project manager.

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