Chronic Care Management (CCM)

Engagement: Subscription | Delivery Time: 3-4 weeks | Tier: Growth

Project Summary: Build-and-run CCM compliant with time thresholds and billing.

Deliverables

• Patient enrollment
• Monthly coordination
• Billing enablement

ROI Impact: CCM revenue ↑, outcomes ↑

Great For: Medicare-heavy panels

Chronic conditions account for the majority of healthcare costs and patient complexity. Yet many practices struggle to consistently deliver the care coordination required to improve outcomes and capture available reimbursement. The Chronic Care Management (CCM) service provides a turnkey framework to operationalize CCM, ensuring compliance with CMS requirements while creating a sustainable revenue stream.

What’s Included:

• Program Design & Compliance
  • CMS‑compliant CCM program tailored to your patient population.
  • Documentation templates and workflows aligned with CPT codes (99490, 99439, 99487, 99489).
• Patient Identification & Enrollment
  • Data analysis to identify eligible patients with two or more chronic conditions.
  • Outreach campaigns to engage and enroll patients into the CCM program.
• Care Coordination & Management
  • Structured monthly non‑face‑to‑face care management activities.
  • Medication reconciliation, care plan development, and coordination with specialists.
• Staff Training & Workflow Integration
  • Training for providers and staff on CCM documentation and billing requirements.
  • Seamless integration into EHR and scheduling systems.
• Revenue Optimization
  • Guidance on accurate coding and billing for CCM services.
  • Ongoing monitoring to ensure maximum reimbursement capture.
• Performance Dashboards
  • Real‑time visibility into patient enrollment, care management activities, and revenue impact.
  • Monthly executive reports linking CCM performance to financial and clinical outcomes.

Why It Matters

CCM is more than a billing opportunity—it’s a strategic care model that improves patient outcomes, reduces hospitalizations, and strengthens value‑based care performance. With CCM Optimization, your practice gains a structured, compliant, and profitable approach to managing chronic conditions while building stronger patient relationships.

♻️ Before & After CCM Snapshot