The Complete Guide to Chronic Care Management

CCM Program aims to provide continuous care to chronic patients.

Chronic care management is a programme that has been developed to ensure complete and continuous care to the patients while also helping the providers generate more revenue. 

The CCM program was built to manage the chronic conditions of patients. Chronic diseases need continuous monitoring, and therefore, a patient with chronic illness has to visit the hospital more often.

Regularly visiting the hospital is tedious and a financial load as well. A lot of times, because of busy schedules and distance, patients don’t show up. This causes revenue loss for the providers. 

Chronic Care Management programs are made to address these issues.

Building patient care management requires intense planning and proper implementation. Let’s take a look at various steps of Chronic Care Management. 

Step 1: Develop a Chronic Care Management Program 

The very first step in any CCM program is to develop a program. The development process for a patient care management program requires two things:

  • Preparing the staff 

According to CCM guidelines, any CCM program must have designated care managers. They can be a practitioner of any of these certified individuals:

  • Licensed nurses
  • Health coaches 
  • Medical assistant 
  • Developing the program 

Any Chronic Care Management program must identify and satisfy the following three criteria:

  • What is the problem?
  • What are the solutions?
  • What are the goals?

Step 2: Identify the Patient 

Medicare reimbursement is only given for those patients who have two or more chronic illnesses. The other key point here is that the illnesses must last longer than 12 months.  Therefore, the very first step of building a program is to identify the patients. The patients you shortlist for your CCM program must benefit from it.

Step 3: Patient Outreach 

After identifying and shortlisting the patients, the next step is to reach out to them. This can be done in various ways. Providers can have outreach campaigns, or they can simply talk about Chronic Care Management programs during patients’ regular visits. The main aim of reaching out is to raise awareness about chronic conditions and how CCM programs provide managed care to chronic stricken patients. 

Step 4: Patient Enrollment 

Once the patient has agreed to join the Medicare program, the next step is the enrollment process. Patient enrollment requires the patients’ written consent, and they must fill a detailed form that must include billing information about the program. 

Step 5: Patient Engagement

Once a patient has enrolled in the program, they must be assessed immediately. The patient centred care provided to the enrolled patients must focus on physical, psychological and medical factors. 

To engage patients in the CCM program, they must be provided managed care. 

  • Engaging patients via calls and mails 
  • Providing a continuous assessment of patients’ mental, physical, psychological needs. 
  • Coordinating with other care providers about patients’ condition 
  • Record patients’ health data and progress 

Step 6: Billing 

Under the CCM guidelines, there is a detailed guide on how to bill for Chronic Care Management services. For each patient, monthly billing is done based on the billing codes provided by CMS. 

To bill a patient for patient-centred care, the providers must have a 20 minutes engagement with the patient. 

For a 20 minutes engagement, the billing code is CPT 99490 for a total of $42.00. 

With Chronic Care Management, providers aim to increase their revenue while providing continuous patient centred care.