Chronic Care Management

Understanding CCM
Chronic Care Management (CCM) is the remote services provided to Medicare beneficiaries who have multiple, significant chronic conditions. Besides face-to-face encounters, these services include communication with all others treating health professionals and of course the patient for care coordination (electronically and by phone), medication management, and being accessible round the clock to patients and any care providers. The creation and revision of electronic care plans is also an important key component of CCM.


What’s in CCM for healthcare practices, & what are some barriers to adoption?
In an article for Becker’s Hospital Review, Zachary Blunt says CCM has not being adopted as widely as CMS had anticipated. Blunt cites confusion about billing, fears that documentation will be time taking and a general aversion to placing an additional administrative burden on staff as common barriers to the CCM program adoption process.
Blunt said that practices can overcome these barriers and start to reap the financial rewards of the CCM program by implementing just five simple practices. He advises practices to:

  • Create a standard CCM enrolment workflow. Practices can set up their electronic health record to automatically flag patients as eligible for the CCM program and follow-up remotely.
  • Develop repeatable processes. Practices should understand what CCM needs 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.
  • Regularly check-in on the program. Practices should stick to regularly evaluate enrolment numbers and assess how their CCM program is providing value to patient participants.
  • Look for commercial payer reimbursement opportunities. Blunt notes that commercial payers will often reimburse for CCM-related activities at a 15 to 20 % more than Medicare.


Reaping financial benefits
By billing for CCM, practices can boost revenues and cut expenses. A Mathematica Policy Research Group study shows that providing CCM services reduced growth in total monthly expenditures (USD 73.71 per patient over 18 months while averaging revenues of USD 17.93) whenever a patient received healthcare services for a specific condition within a month. CCM program savings were USD 92.34 per beneficiary per month when beneficiaries received healthcare services more than once in that month.


The report, which monitored costs for patients enrolled in CCM programs vs expenses for non-CCM patients between 2017 and 2019, also suggests that practices adopting CCM will score way better in the cost category of the Merit-based Incentive Payment System’s performance parameters.

These results largely flow from the advanced care that CCM has delivered by increasing patient’s connections with their primary care provider and decreasing emergency department and hospital visits.

Adopting the right mind set

Fee-for-service (FFS) billing is still being used by most of the practices. But if practices are to cope with CCM’s admin, billing, documentation, and clinical requirements, they must change their FFS mind-set, says William Mills, MD, ABIM, founder of Chronic Care Management.