CHRONIC CARE MANAGEMENT

CCM stands for Chronic Care Management, a program covered under Medicare Part B, designed for patients managing two or more chronic conditions. Clinical staff dedicate a minimum of 20 minutes per month to engage with patients, coordinating various care activities.

Research has indicated that participation in CCM programs can lead to a decrease in hospital admissions and contribute to long-term reductions in healthcare costs. Additionally, healthcare providers receive reimbursement per patient for delivering this valuable service.

Common conditions include but are not limited to:

• Alzheimer’s disease and related dementia
• Cardiovascular disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Depression
• Diabetes
• Hypertension
• Infectious diseases such as HIV/AIDS

Patients experience the advantages of coordinated care and heightened engagement as they collaborate with care managers to attain their desired health objectives. Central to this approach is the development of a patient-centered care plan.

CCM services encompass a range of activities, such as monthly clinical reviews, telephone check-ins, physician consultations, referrals, prescription management, chart reviews, and assistance with scheduling appointments or accessing services.

• Physicians
• Physician assistants
• Nurse practitioners
• Certified nurse midwives
• Clinical nurse specialists
• Pharmacists

Enrollment occurs during an in-person evaluation or Annual Wellness Visit, where written or verbal consent must be recorded.

The provider is responsible for explaining to the patient:

• The advantages of CCM for their health
• Medicare Part-B's coverage of 80% with a co-pay
• Their ability to opt out of the program at any time

Chronic Care Management CPT codes:
99490, 99491, 99439, and more