Story by CCS Editor / March 21, 2025
Chronic Care Management (CCM) is a Medicare program designed to improve care for patients with multiple chronic conditions while streamlining healthcare coordination for providers. With a focus on proactive and continuous care, CCM helps patients manage their health more effectively while reducing hospital visits and improving overall well-being.
This guide provides a clear breakdown of Chronic Care Management, who qualifies, how it works, and what benefits it offers for both patients and providers.
A chronic condition is a long-term illness that requires ongoing medical attention. These conditions typically last for at least 12 months or longer and may significantly impact a person’s daily life. Managing chronic illnesses often involves multiple medications, regular doctor visits, and lifestyle adjustments.
To qualify for CCM, Medicare patients must have at least two or more chronic conditions. Some common qualifying conditions include:
CCM services help patients stay on track with their health by providing non-face-to-face medical support between visits. These services are a Medicare Part B benefit and are intended to improve patient outcomes while reducing healthcare costs.
Key CCM services include:
CCM services can be classified as either standard or complex. Complex CCM involves higher-level decision-making and typically requires additional time spent on patient care.
After enrollment, the provider creates a personalized care plan that addresses the patient’s specific health needs. The plan includes:
This structured plan ensures continuity of care and helps patients take a more active role in managing their conditions.
CCM services must be provided under the supervision of a Medicare-qualified provider, which includes:
While registered nurses, licensed practical nurses, and medical assistants can contribute to care coordination, Medicare requires that CCM services be overseen by an eligible supervising provider.
Medicare uses CPT codes to define how CCM services are billed. These include:
Only one provider can bill Medicare for CCM services per patient each month.
Principal Care Management (PCM) is a newer Medicare program that began in 2020. While CCM covers patients with two or more chronic conditions, PCM is designed for patients with one high-risk chronic condition requiring intensive management.
PCM services are billed separately from CCM and may be beneficial for patients who need focused care for a single complex condition.
At Chronic Care Staffing, we help healthcare providers implement turnkey CCM solutions that improve patient care while reducing the administrative burden. Our team specializes in care coordination, compliance, and patient engagement, allowing practices to focus on in-person care while we handle the rest.
If you’re a provider looking to offer Chronic Care Management, or a patient wanting to explore CCM benefits, contact Chronic Care Staffing today. Our team is ready to help you navigate Medicare CCM services and improve long-term health outcomes.
