Physicians Complete Guide to Chronic Care Management

        Senior citizens with one or more chronic conditions have a hard time managing their health. CMS was spending a lot of money on patient’s insurance who were suffering from chronic conditions. In order to cut down the expenses on hospital admissions, the CMS introduced the Chronic Care Management program. Patients usually visit their physicians for chronic care once or twice a year. With a Chronic Care Management program, a patient’s health improves due to increased attention and care. They can also spend less time on health issues and more on what they like to do.

What is Chronic Care Management?

Medicare defines Chronic Care Management program as non-face-to-face service provided to its beneficiaries with multiple (two or more) significant chronic conditions. In addition to office visits and other face-to-face encounters (billed separately), these services include

  • Communication with the patient
  • Health professionals being available both electronically and by phone for care coordination, medication management, and being accessible to patients.

Time-consuming process

Despite the increased Medicare reimbursement rates, patients do not get CCM services due to the physician’s time constraints. Chronic Care Management program requires a lot of time and effort from the physician. Unfortunately, providers must meet a number of requirements to qualify for a CCM Medicare reimbursement. These include:  

  • Twenty minutes of non-face-to-face conversation per month with the patient
  • Use of a certified EHR
  • Create a patient care plan based on the assessments and available resources
  • Provide the patient with a copy of the monthly updated care plan and document the same in the EHR
  • Ensure that the care plan is available electronically to anyone within the practice providing CCM services
  • Share the care plan electronically outside the practice as appropriate  
  • Ensure 24/7 access to care management services
  • Ensure continuity of care with a designated practitioner or member of the care team who will take care of successive routine appointments

The list goes on at considerable length defining the care practice must give. The fact sheet offered by the CMS goes up to eleven pages with multiple requirements to bill for CPT code 99490. This can become quite cumbersome for any practice, considering that the Medicare reimbursements are only $42.60/patient/month.

Steps to improve the Chronic Care Management program

1.Building a strong team

If a practice chooses to offer CCM services, it will be an investment. The demands include

  • Additional staffing with additional salaries,
  • Benefits and increased workload for management.
  • Additional office space depending on your current facility
  • It is important for the practice to set up a plan of action to calculate the required additional staff members required and the exact cost of this service. The practice must,
  • Start by assessing how many patients in the practice will be eligible to receive CCM services. 
  • Identify how many people are needed to give quality CCM services to their patients and also additional salaries and benefits, added office space, etc.
  • It is important to analyze the merits and demerits from a financial perspective. Even if a practice is not profiting from CCM in the first stages, it is always possible to derive profit later.

2.Outsourcing Chronic Care Management services

Many private practices and hospitals who want to offer CCM services but cannot the implementation process can opt for outsourcing their CCM. There are vendors who provide this service and understand the new requirements better for reimbursement eligibility. In essence, they become an extension of the practice and require minimal financial investment from the provider. By this, the practice can manage the risk factors, patient experience, and profit better. A study on outsourcing chronic care management for diabetes patients found that those who participated in the outsourced care,

  • Rated the experience more positively
  • Demonstrated better clinical outcomes than those who received clinic-based care

3.Using a Chronic Care Management software

Chronic Care Management software can reduce the time and the manual effort spent in giving the CCM services. HealthViewX Chronic Care Management solution has the following features that make the process simpler,

  • Inbuilt audio, video calling and messaging features – HealthViewX Chronic Care Management solution has inbuilt video and audio calling features. It helps in giving Chronic Care Management services to their patients. Secure messaging is also available through which the physicians and the patients can communicate.
  • Automated call log feature – After a call, care plan creation or any action related to CCM health services, the system automatically adds call logs. It reduces the physician’s manual effort is logging the call logs.
  • Preventive Care plans – HealthViewX solution supports care plans for the Chronic Care Management service for a patient. The physician can create a care plan depending on the patient’s health report. It helps in monitoring the patient’s vitals.
  • Chronic Care Management Analytics – Dashboards with intuitive charts and tables give complete analytics of the Chronic Care Management services. It provides a clear picture of the revenue perspective.
  • Consolidated Report – The physician can generate a consolidated report of the Chronic Care Management services given for a particular period. This makes it easy for the billing practitioner for getting the Medicare reimbursements.
  • HIPAA compliance – HealthViewX Chronic Care Management is HIPAA-compliant. It facilitates secure data exchange. The solution manages all patient-related documents securely.

A healthcare practice following the above steps will find significant improvement in their Chronic Care Management program. HealthViewX Chronic Care Management software has features that suit practices as well as CCM vendors. To know more about our Chronic Care Management solution, schedule a demo with us.



Wolf, M. S., Seligman, H., Davis, T. C., Fleming, D. A., Curtis, L. M., Pandit, A. U., … & DeWalt, D. A. (2014). Clinic-Based Versus Outsourced Implementation of a Diabetes Health Literacy Intervention. Journal of general internal medicine, 29(1), 59-67.