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Chronic Care Management (CCM) is billable care coordination services, conducted outside of regular office visits, for Medicare patients with two or more chronic conditions. These services routinely require extra time for physicians and clinical staff (e.g., coordinating refills with the pharmacy, discussing symptoms with the patient and/or their family, checking that labs and other measurable parameters are within target ranges).
- Record the patient health information using an electronic health record
- Create and maintain a comprehensive care plan to address all health issues, with special focus on their chronic conditions
- Provide 24/7 access to physicians or clinical staff
- Manage care transitions.
Before CCM services can begin, you’ll need to conduct an initiating visit with new patients or patients you haven’t seen within a year. During this visit, you’ll discuss their interest and eligibility for these services and obtain their consent before billing for CCM.
Check out this fact sheet to learn more about the elements of CCM and the requirements to provide its services.
CCM is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. While it may take some time and effort to get fully up to speed, these services will help to improve the care you provide. Learn more about how CCM can benefit your practice by downloading this toolkit.