Checklist for Developing a Chronic Care Management Program

Are you with one of the many organizations considering whether to establish a chronic care management (CCM) program? You've come to the right place! In this piece, which combines valuable background information, guidance, and a detailed checklist, you'll gain a better understanding of chronic care management as a concept, the value of CCM, and the steps you take that will better ensure you develop a strong program that meets your patients' and organization's short- and long-term needs.

Let's start by defining CCM.  

Definition of Chronic Care Management 

Chronic care management (CCM) services are generally non-face-to-face services provided to Medicare beneficiaries with two or more chronic conditions (e.g., hypertension, diabetes, obesity, chronic obstructive pulmonary disease (COPD), hyperlipidemia) expected to last at least 12 months. CCM includes the creation of a comprehensive care plan and providing ongoing health support services.

Physicians, qualified health professionals (QHPs), and "clinical staff" can provide CCM services to patients. Clinical staff operate under general supervision of a physician or QHP and may include medical assistants, social workers, pharmacists, and registered dieticians.

Now that we have a better understanding of CCM, let's take a quick look at the financial and clinical value of CCM.

Why Organizations Need a Chronic Care Management Program 

A chronic care management program helps ensure an organization is compensated for the care provided to patients outside of the normal confines of regular office visits. On average, Medicare reimburses about $62 per calendar month per patient in 2024 for the minimum provision of non-complex CCM services, making the service both an effective care modality for your most vulnerable patients and a consistent, high-revenue-generating service for the providing organization. 

Assuming 20 minutes of care management time per patient per month (the minimum billing opportunity), a CCM program with 100 enrolled patients could annually generate $73,200. A CCM program with 500 enrolled patients would generate $366,000.

For providers, chronic care management creates a meaningful, recurring source of added revenue; enables more comprehensive patient care; builds patient loyalty and engagement; and helps preserve in-office visits for patients who need them. For patients, CCM improves access to the care team and helpful resources; enables patients to better manage their medications and symptoms; saves money on hospitalizations and costlier, reactive treatments; and encourages a more active role in their health.

Checklist for Developing Your Chronic Care Management Program 

Use the following checklist to help ensure your chronic care management program addresses the key facets required for establishing, growing, and billing CCM. 

Identify Your Chronic Care Management Goals and Cohort (identify patients and their chronic conditions) 

Determine the number and type of patients your CCM care team is prepared to manage. Answer these questions:  

• How many patients can the care team manage effectively?  

• Do you intend to incorporate any remote patient monitoring (RPM)? If so, what kind of technology will need to be put in place?

• Which chronic conditions are most reflected in your patient population?

• Which of those chronic conditions will your care team most effectively manage?

• Which of those conditions pose the most mitigable risk to your patients?

• Will your program focus on only high-risk patients, or will it expand to medium- or even low-risk patients?  

• Will your program include patients with all comorbidities or only select conditions?  

• What acute events might trigger patient enrollment into monitoring? Note: For help with determining patients eligible for CCM services, get this quick guide.  

Sketch out your care protocols 

• Given the disease states and patient cohorts you are trying to target, plan out your care protocol and draft corresponding patient care plans.
• Determine what “stop-light” protocols you want in place based on a chronic condition. These will be care plan triggers that initiate an immediate notification to the practitioner.
• Draft out the major areas of your care plans:
  • Patient goals (e.g., diet, exercise)
  • Common barriers the patient might run into (e.g., social determinants of health)
  • Medication management (if applicable)
  • Social and community resources
• Determine if/which metrics need to be documented depending on the chronic disease(s) being managed. Examples of specific metrics include:
  • Pain level
  • Blood pressure
  • Blood glucose level
  • Body mass index
  • Resting heart rate

Ensure your cohort and protocols meet the Medicare requirements for CCM 

• Your cohort patients must have two or more chronic conditions expected to last at least 12 months or until death.  
• Those chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.  

Establishing the Internal Framework (ensuring your organization is ready to deliver chronic care management services) 

Ensure you can meet Medicare’s requirements for providing CCM 

• Offer 24/7 access to physicians or other qualified healthcare team members. This can be accomplished through the telephone or telehealth modalities such as a secure internet portal or email.  
• Use a certified EHR system defined by “meaningful use” guidelines. 

Designate care team member(s) 

• Designate or hire qualified staff who can dedicate the time needed for CCM patient care activities, such as appointments, coordination of care, and regular check-ins. 

Create technology infrastructure 

• Develop appropriate CCM templates and time-tracking capabilities within an existing EMR or partner with a technology platform (e.g., Prevounce) that will accurately track time and help organize documentation related to all CCM patient activities.  

Develop ability to identify qualified CCM patients 

• Establish processes by which you can identify patients who qualify for care management services (e.g., reporting system or service that can extract data on qualified patients based on diagnosis). Note: If you need assistance with establishing such processes and are a Prevounce client, speak with your account representative.  

Create standardized medical record 

• Develop and use a standardized medical record that collects and maintains required data and information for the charting and billing of CCM services.  
  

Providing Chronic Care Management (establishing your CCM workflow) 

Notify CCM patients 

• Once an eligible patient has been identified, you must inform them of the availability of chronic care management services and any co-insurance/out-of-pocket costs associated with participation.    

Enroll and obtain CCM informed consent 

• Patients must consent that they wish to participate in CCM services. Consent can be verbal or in writing but must be documented in the patient's medical record. 

Provide care management 

• Schedule when and how patient outreach will occur. This should be individualized and based on each patient’s needs, per physician orders. 
• Determine which communication modalities, or combination of modalities, you intend to use for care management purposes (e.g., phone, video chat, secure email). 
• Plan and schedule ongoing care plan updates and patient check-ins. 
• Record all time spent on managing the patient's care plan, reviewing diagnostics and vital measurements, coordinating care, discussing the patient’s social determinants of health, and any other patient-related communications or activities.  

Produce CCM care plan 

• Create and document the patient’s care plan, ensuring they receive a copy. 

Maintain documentation 

• Documentation must be maintained within the patient’s medical record that CCM was explained in full, with notation of whether the patient accepted or declined to participate in CCM services. 

Securing Patient Buy-in and Setting Expectations

• Explain what CCM is. Consider creating patient education material.
• Explain the time commitment associated with participation and nature of that time commitment (i.e., speaking with care managers on the phone).
• Explain cost associated with participation. If the patient objects, explain cost relative to expensive hospital visits, procedures, etc., they might be able to avoid.
• Explain who is going to be involved. This is a coordinated care team, not just their doctor.
• Explain the value of the program. These services will help keep them healthy, avoid adverse events, and navigate their care more easily (e.g., medications, specialist visits).

Establishing Patient Goals and Securing Engagement (keep patients on track)

• Set SMART goals that are specific, measurable, attainable, relevant, and timely. Include patients in your goal setting.
• Encourage patient self-monitoring (e.g., patients keep a journal of progress on a goal).
• Consider using Motivational Interviewing techniques, which have proven to be effective at promoting behavior change.
• Maintain consistent communication, preferably with the same care manager or small group of care managers to establish meaningful bonds. 
• Celebrate successes — big or small — and continuously remind patients why they're participating in the program.

Getting Paid (meet the billing requirements for chronic care management) 

Below are the seven chronic care management codes that can be used to bill CCM services. We've included their 2024 Medicare non-facility reimbursement rates for your reference. 

• CPT 99490 — Used for the first 20 minutes of a calendar month for the purpose of chronic care management using clinical staff time and directed by a physician or other qualified health professional. 2024 reimbursement: ~$62
• CPT 99491 — For CCM services that total at least 30 minutes per calendar month. To use this code, the services must have been provided by a physician or other qualified healthcare professional. 2024 reimbursement: ~$83
• CPT 99439 — This code is used in addition to 99490 capture additional care that exceeds the 20-minute time allotment. 99439 is used for every additional 20-minute increment of service time and may be used up to two times for a maximum of 60 minutes total. 2024 reimbursement: ~$47
• CPT 99437 — This code is used in addition to 99491 capture additional care that exceeds the 30-minute time allotment. 99437 is used for an additional 30-minute increment of service time and may be used once for a maximum of 60 minutes total. 2024 reimbursement: ~$59
• CPT 99487 — This code is for complex CCM services that total at least 60 minutes of clinical staff time per calendar month. This time must be directed by a physician or other qualified healthcare professional. Complex CCM patients are those who require moderate- to high-complexity medical decision-making. 2024 reimbursement: ~$132
• CPT 99489 — This code is used for an additional 30-minute increment of complex CCM provided to the patient in a calendar month. 2024 reimbursement: ~$71  
  G0511 — This code is only used by federally qualified health centers (FQHC) and rural health centers (RHC) for at least 20 minutes of providing care management services. 2024 reimbursement: ~$73

To learn more about coding and billing for chronic care management, download this guide.

Want more advice on building a successful CCM program? Watch this on-demand webinar. 

Need Help Establishing a CCM Program? 

Reach out the team at Prevounce! With Prevounce, you can stay focused on what matters: healthy patients, compliant programs, and meaningful revenue. Get the people, software, experience, and support you need to make your chronic care management programs truly successful. Our best practices and CCM experts help clients nationwide overcome obstacles and achieve success. To learn more, schedule a demo. 

CPT Copyright 2024 American Medical Association. All rights reserved. 
CPT® is a registered trademark of the American Medical Association. 

Disclaimer

Health economic and reimbursement information provided by Prevounce is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules, and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice.

Prevounce encourages providers to submit accurate and appropriate claims for services. It is always the provider’s responsibility to determine medical necessity, the proper site for delivery of any services, and to submit appropriate codes, charges, and modifiers for services rendered. It is also always the provider’s responsibility to understand and comply with Medicare national coverage determinations (NCD), Medicare local coverage determinations (LCD), and any other coverage requirements established by relevant payers which can be updated frequently.

Prevounce recommends that you consult with your payers, reimbursement specialists, and/or legal counsel regarding coding, coverage, and reimbursement matters.

Payer policies will vary and should be verified prior to treatment for limitations on diagnosis, coding, or site of service requirements.

The coding options listed here are commonly used codes and are not intended to be an all- inclusive list. We recommend consulting your relevant manuals for appropriate coding options.

The Health Care Provider (HCP) is solely responsible for selecting the site of service and treatment modalities appropriate for the patient based on medically appropriate needs of that patient and the independent medical judgement of the HCP.