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Jul 18

Chronic Care Management: 4 Best Practices

Providing comprehensive patient care is the most important task a clinician faces each day. When patients are dealing with chronic conditions, that task becomes all the more vital. This is why chronic care management is so important. Read on to learn more about this program and four CCM best practices to help you see success.

What is chronic care management?

Roughly 117 million adults in the United States have at least one chronic health condition, with 25% of adults having at least two chronic health conditions. Adequately monitoring these conditions is integral to positive health outcomes. Chronic care management (CCM) consists of care coordination performed outside of regular office visits for patients experiencing at least two chronic health conditions that are expected to last at least one year or until the patient’s death. In order for a patient to be eligible for CCM, their conditions must put them at a significant risk of death or functional decline.

Chronic care management allows providers to bill for non-face-to-face care coordination services totaling at least 20 minutes per month. Physicians, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives are all eligible to bill for CCM services. Critical access hospitals, FQHCs, and rural health clinics are eligible to bill for CCM services as well. However, CCM reimbursement is only paid to one provider per patient per month.

4 CCM Best Practices

Chronic care management is an important piece of the patient care puzzle, and it’s important to streamline this process for the best results. Here are four best practices to help you do just that.

  1. Get consent from patients in advance. You must document each patient’s consent in their medical record prior to providing or billing for CCM. When obtaining this consent, make sure the patient understands that only one provider can give them CCM services in any month and that the patient can opt out at any time. Also make sure to thoroughly explain what is involved in CCM so that patients can understand what to expect.
  2. Keep a complete record of time spent providing CCM services. It’s important to have an accurate record of the time spent providing applicable services to each CCM patient. Prescription management, phone calls to patients, care coordination with other providers and facilities, and medication reconciliation all count toward CCM.
  3. Have a thorough understanding of the codes and steps to bill for CCM. In order to submit a claim for chronic care management, you’ll need applicable CPT codes, the ICD-10 codes for all conditions being managed, dates of service, place of service, and your NPI number. Once you’ve calculated the time spent on a patient in a given month, you’ll first verify that all requirements have been met. Then it’s time to submit the claim, send an invoice to CCM patients, and ensure that no conflicting codes have been billed.
  4. Create comprehensive care plans. Chronic care management requirements include a comprehensive care plan for each patient receiving CCM services. This plan should include a full assessment of the patient’s needs, a list of the patient’s conditions emphasizing those which are chronic, treatment goals with targeted outcomes, a list of individuals and resources involved in patient care, and medication management records. The care plan must be available to the patient, any caregivers, and all other providers involved in their care.

Whether you’re a seasoned pro when it comes to providing CCM services, or you’ve just decided to add this process to your practice, being aware of these best practices will help to ensure that your CCM program is a successful endeavor. It’s also important, when delving into CCM, to be sure that you have the right tools to get the job done efficiently. That’s where Henry Schein MicroMD comes in. Our simple, customizable, connected EMR provides you with the resources you need to efficiently perform, track, and bill for CCM services.

Are you ready for more information? Visit or call 1-800-624-8832 today.

About the author,
Crystal Stanton

Crystal is a Digital Marketing Specialist at Henry Schein MicroMD. Content creation, social media management, and SEO optimization are just a few of her areas of concentration as she seeks to educate clients and prospects alike about the simple, customizable, and connected solutions we offer at MicroMD.

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