What We Do

Maximize MIPS & MACRA Valuations

CCS calling protocols help improve your MIPS score on your PQRS report. Our Care Coordinators help implement HEDIS (Quality and Outcome) measures chosen by the providers. Working directly into the practice EHR, we chart quantifiable data that helps scores on the QRUR. Value Based Reimbursement Program Assessments

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Chronic Care Management

We remotely login into the practice EHR, maintaining patient privacy and security. CMS code CPT 99490 pays a national reimbursement average of $46.00/call. We maximize your CCM program with a 90% monthly billed average of enrolled patients. Our specially trained nurses increase quality patient care outcomes over our competition. Our CCM program generates additional practice revenue by identifying patients needing follow up interventional care.

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Coordination of Care

We work with your providers to increase patient education and awareness using appointment reminders, by recognizing and reporting changes in patient health status, referral coordination, medication management and reconciliation, and transition of care coordination

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Closing Gaps in Care

Chronic Care Staffing optimizes your AWV program by notifying the practice and the Patient when due. We capture HEDIS and Health Assessment data sets. Also, during an AWV, providers can capture additional revenue (CMS G0506, $63.00) for care planning.

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What is Chronic Care Management?

The Centers for Medicare & Medicaid Services recognize Chronic Care Management (“CCM”) as a critical component of primary care that contributes to better health and care for individuals.

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (CPT 99490) for non Face to Face services furnished to Medicare patients with multiple chronic conditions.

CCM services include at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline
  • Comprehensive care plan established, implemented, revised, or monitored


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  • “Chronic Care Staffing does a fabulous job getting so many patients on the phone. We have gone a long way toward improving people’s health, simply by discovering the number of patients who were out of meds!! Overall feedback from our patients is great. They are all convinced you are sequestered in rear of building. They comment that calls from action items sent by you to us are resolved quickly, adding to feeling you’re just down the hall (confidence)."
    Jeffrey Santi, M.D. - Berkeley Family Practice