Chronic conditions aren’t easy to deal with — as a healthcare provider treating them on a time crunch, as a healthcare system trying to provide adequate care with limited resources, or as one of the two-thirds of Medicare beneficiaries with two or more chronic conditions. Comprehensive care management is designed to help ease these burdens with efficient and personalized care that extends beyond traditional office visits.
By improving patient health, boosting patient engagement, and decreasing total cost of care, comprehensive care management can support everyone working to manage chronic conditions. Integrating two care management services — chronic care management (CCM) and remote patient monitoring (RPM) — helps achieve this comprehensive level of care and deliver on its significant benefits.
Understanding Chronic Care Management (CCM)
Chronic care management was introduced by the Centers for Medicare & Medicaid Services (CMS) to encourage providers to deliver ongoing care coordination for patients with multiple chronic conditions expected to last at least 12 months. CCM helps address the growing burden of chronic diseases on patients and the healthcare system. Since its introduction, CCM has grown to become an essential component of chronic disease management, empowering providers to deliver continuous, coordinated care that improves patient outcomes, enhances engagement, and reduces hospitalizations.
This proactive care approach better ensures seamless communication between patients and their various healthcare providers. Services covered under CCM include:
- Care coordination
- Medication management
- Regular check-ins
- Patient education
Medicare reimbursement makes CCM financially viable for healthcare organizations. Providers can bill for CCM services using specific CPT codes. CPT 99490 covers non-complex CCM, while CPT 99491 applies to services provided directly by a physician or qualified professional. Additional codes, such as CPT 99439 and CPT 99487, cover extended service time. These ensure fair compensation for chronic disease management. CCM pairs well with other remote care management programs, such as remote patient monitoring, as is discussed below.
Note: For an in-depth dive into key concepts about CCM, such as eligible conditions, billing, and coding, access this guide.
Understanding Remote Patient Monitoring (RPM)
Remote patient monitoring (RPM), sometimes referred to as remote physiological monitoring, is the use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions. RPM allows providers to continue tracking healthcare data for patients between office visits.
RPM plays a crucial role in managing chronic conditions by delivering real-time health data to healthcare providers. By continuously tracking physiological health data, RPM allows providers to detect early warning signs, adjust treatment plans as needed, and prevent complications before they escalate. This proactive approach helps patients manage their conditions more effectively while reducing hospital admissions and emergency room visits.
Patients with chronic conditions that often benefit greatly from RPM include:
- Hypertension
- Diabetes
- Chronic obstructive pulmonary disease (COPD)
- Congestive heart failure (CHF)
- Obesity
- Asthma
Various RPM devices are used to monitor these conditions, helping providers gather critical health insights. Common devices and their associated conditions include:
- Blood pressure monitors – used for hypertension and cardiovascular health
- Glucose meters – essential for diabetes management
- Pulse oximeters – help monitor oxygen levels in COPD and asthma patients
- Weight scales – track weight fluctuations for CHF and obesity management
Note: To gain a better understanding of each of these devices and how they can be used to improve patient outcomes, read “4 Remote Patient Monitoring Devices to Know.”
Benefits of Integrating RPM With CCM
Integrating remote patient monitoring with chronic care management is a game-changer for both patients and healthcare providers, leading to improved patient outcomes, better practice efficiency, and enhanced revenue opportunities. Let’s take a closer look at each of these areas and how the integration of RPM with CCM makes them a reality.
Improved Patient Outcomes
With RPM, providers receive real-time data on key health indicators such as blood pressure, glucose levels, and weight. This ongoing stream of information allows care teams to track trends, adjust treatment plans as needed, and respond quickly to any concerning changes. When paired with CCM, which includes structured care coordination and regular patient interactions, this approach ensures that chronic conditions are managed more effectively, reducing disease progression and enhancing overall health.
Better disease management through RPM and CCM leads to early detection of complications and fewer hospitalizations. Many chronic conditions, like hypertension, diabetes, and heart disease, require consistent monitoring to prevent complications. Without real-time oversight, issues often go unnoticed until they require emergency care. By integrating RPM, providers can detect warning signs early and intervene before a patient’s condition worsens, helping to avoid costly and stressful hospital stays. This not only improves patient well-being, but also reduces strain on healthcare systems.
When RPM and CCM are combined, patients become more engaged in their own care and management of their chronic condition. Regular check-ins from care teams and feedback on health data from RPM provides patients with real-time insights into their health. This reinforces positive behaviors and encourages adherence to care plans.
Better Efficiency in Care Coordination and Delivery
Pairing RPM with CCM transforms care coordination because healthcare teams now have access to real-time patient data. Instead of relying solely on periodic office visits, providers can continuously monitor patients’ conditions and intervene before complications arise. With more timely access to vital health data, care teams can make informed decisions quicker, allowing for more personalized and responsive patient care.
A well-integrated RPM and CCM platform also streamlines workflows, reducing administrative burdens on providers and clinical staff. Automated data collection minimizes manual documentation, freeing up time for direct patient engagement. Data from RPM enables care providers to track progress, adjust care plans, and communicate seamlessly, leading to a more efficient care model.
Enhanced Revenue Opportunities
Combining RPM with CCM also creates a strong financial opportunity for healthcare organizations. Many organizations will bill the base monthly RPM code (CPT 99454), which covers RPM device supply and requires at least 16-days of transmitted data per 30-day period, and bill CCM codes (like CPT 99490 and CPT 99491) for time spent reviewing patient data, adjusting treatment plans, and providing ongoing communication. Through dual enrollment of patients in these complementary programs, practices can appropriately maximize the revenue from their comprehensive care management program.
Here’s what dually enrolled billing looks like when combining CCM with RPM:
Key Steps to Successfully Implement Comprehensive Care Management
Successfully implementing a comprehensive care management program that combines CCM and RPM requires careful planning and the right tools. By following best practices, healthcare providers can create a sustainable comprehensive care management model that enhances both patient care and organization revenue. Key steps include assessing patient eligibility, selecting the right technology, delivering detailed training, and executing proper coding and billing. Let’s take a closer look at each and what’s required for success.
Assess Patient Eligibility
Assessing patient eligibility for a combined RPM and CCM program starts with identifying Medicare beneficiaries who have two or more chronic conditions expected to last at least 12 months. These patients may be at risk of deterioration or hospitalization, making them strong candidates for proactive management.
In addition to clinical criteria, it's important to consider patient engagement. Those who are motivated to take an active role in their health and willing to use RPM devices tend to benefit the most from remote patient monitoring and chronic care management.
Select and Integrate the Right RPM and CCM Technology
Choosing the right RPM and CCM technology starts with selecting user-friendly devices that align with patients’ conditions and help ensure the delivery of health data. Cellular devices with simple setup and automatic data transmission encourage patient compliance and improve engagement. Reliable data transfer between RPM devices and the care management platform (e.g., Prevounce) is crucial for real-time monitoring.
Equally important is ensuring compliance with Medicare and payer requirements. The chosen platform should support proper documentation, meet HIPAA standards, and cover all key clinical workflows.
Note: For more information on selecting the right technology for your organization, download “A Nuts & Bolts Guide to Remote Patient Monitoring Technology.”
Train Healthcare Providers and Patients
Healthcare providers and patients should be educated on a variety of RPM and CCM topics, including proper device usage, data interpretation, and how remote monitoring fits into patient care plans. Providers and patients need to feel comfortable using the devices and understanding the data being collected. Listening to feedback from both groups can help an organization improve workflows and address any challenges. Keeping communication open, updating care plans as needed, and offering ongoing support and training ensures everyone stays engaged and confident in the process.
Ensure Proper RPM and CCM Coding and Billing
Proper coding and billing of RPM and CCM are critical steps to successfully implementing a comprehensive care management program. Accurately and thoroughly documenting services while using the correct CPT codes help ensure providers receive full reimbursement while maintaining compliance with CMS and commercial payer requirements. Mistakes in coding and billing can lead to denied claims, audits, or lost revenue. With RPM services under increased scrutiny, including audits by the Office of Inspector General (OIG), accurate coding and billing are more essential than ever.
Integrating RPM With CCM: Key Takeaways
Integrating RPM with CCM enhances patient outcomes, streamlines care coordination, and creates new revenue opportunities for healthcare organizations. By combining real-time health monitoring with structured care management, providers can deliver proactive, patient-centered care that reduces hospitalizations and improves chronic disease management.
To implement a successful and compliant comprehensive care management program, choosing an experienced partner like Prevounce is essential. Prevounce offers a complete solution — including RPM devices, a user-friendly platform, and care management services — that simplifies program administration while better ensuring compliance with CMS requirements. With Prevounce, healthcare organizations can focus on patient care without the added burden of complex workflows and billing challenges.
Speak With A Comprehensive Care Management Expert
Schedule a consultation with Prevounce to learn how our platform and people simplify the launch and growth of a comprehensive care management program that achieves improved patient outcomes and delivers recurring and scalable revenue.