CCM for Kidney Care: Supporting CKD Patients Between Nephrology Visits

Mr. Ellis left his nephrology appointment motivated: a tighter blood pressure goal, a sodium target, an ACE inhibitor refill, and a lab slip for urine albumin-to-creatinine ratio (UACR) and estimated glomerular filtration rate (eGFR) in six weeks. Then life happened. Between a move, a new grandchild, and a stubborn cough, the plan scattered. By the next visit, blood pressure had crept up, sodium intake had inched higher, and the labs were overdue—again. That gap between visits is where Chronic Care Management (CCM) does its quiet, essential work: structured monthly touchpoints that keep the plan intact, coordinate across clinicians, and make the next visit about progress rather than catch-up. CCM is a defined Medicare Part B service furnished when a patient has two or more chronic conditions expected to last at least 12 months (or until death) that place the patient at significant risk, supported by a comprehensive, shareable care plan, documented consent, and 24/7 access and continuity of care.

What CCM is, through a kidney lens

CCM is a calendar-month care management service that pays for the non–face-to-face work required to keep complex patients on track. Only one practitioner can bill CCM for a given patient in a given month, and the program’s scope includes developing and updating an electronic care plan, coordinating across clinicians and settings, managing medications, tracking labs and imaging, and ensuring patients have around-the-clock access to address urgent issues. [1] For kidney care, that translates directly to the building blocks of chronic kidney disease (CKD) management: blood pressure and glycemic control, albuminuria surveillance, guideline-directed medical therapy, and tight coordination with primary care, cardiology, endocrinology, and nephrology. These steps are associated with slower CKD progression and fewer complications when performed reliably over time.

CKD by the numbers, why the “between visits” interval matters

CKD affects about 37 million adults in the United States, many of whom are undiagnosed until kidney function has already declined. The condition raises risks for cardiovascular events, hospitalization, and mortality, and it is often driven by modifiable factors—including hypertension and diabetes—that respond to steady, supported self-management. [5] In practical terms, what happens between nephrology visits determines whether a patient’s plan becomes a daily routine or a good intention that fades. CCM’s monthly cadence and continuity are a match for CKD’s slow, cumulative trajectory.

How CCM supports kidney care, month by month

Every practice will tailor CCM to its population, but the most effective programs share a consistent pattern: plan, coach, verify, and escalate when needed.

• Precision goal setting and a shareable plan. The CCM team translates nephrology goals (for example, blood pressure target, ACE inhibitor/angiotensin receptor blocker (ACEi/ARB) or sodium–glucose cotransporter-2 inhibitor (SGLT2i) use, diuretic adjustments, sodium restriction, and smoking cessation support) into a patient-friendly electronic care plan available across the care team.
• Blood pressure and glycemic management. Monthly outreach confirms medication access and adherence, reinforces home blood pressure monitoring technique, and problem-solves barriers (cough from ACEi, orthostasis from diuretics). For patients with diabetes, coordinators confirm self-monitoring routines or continuous glucose monitor (CGM) use and help schedule A1C and UACR testing per guideline cadence.
• Albuminuria and kidney function surveillance. The team tracks due dates for UACR and eGFR, closes the loop on results, and routes abnormalities for timely action (for example, uptitrating RAAS blockade or initiating SGLT2 inhibition when appropriate).
• Sodium, fluid, and nutrition coaching. Brief, structured counseling and micro-goals (reading labels for sodium, swapping processed foods, recognizing hidden salt) compound over time and are easier for patients to implement with monthly reinforcement.
• Comorbidity and medication safety checks. Coordinators watch for nephrotoxin exposure (NSAIDs), ensure vaccination updates, and reconcile medications after hospitalizations or specialist visits, with the billing practitioner maintaining oversight per CMS rules.
• Fast-track escalation. When symptoms change (swelling, dyspnea, uncontrolled pressures, hyperglycemia) the CCM team expedites nephrology or primary care follow-up rather than waiting for the next routine visit, and documents the transition work in the CCM record.

Together, these steps convert guideline intentions into dependable habits. The outcome is a safer “between-visit” interval and a higher-yield clinic encounter.

What CCM can enable in CKD care

These are not promises of specific effect sizes for every population; they are the practical mechanisms by which guideline-concordant care is made dependable in the real world.

Fitting CCM alongside other care management and monitoring

Care episodes do not respect billing boundaries, so clarity matters:

• CCM with Transitional Care Management (TCM). TCM can be billed in the same service period as CCM when medically necessary, provided time is not counted twice. This is common after CKD-related hospitalizations for acute kidney injury (AKI), heart failure, or infections.
• CCM with Principal Care Management (PCM). PCM may run concurrently with CCM when furnished by different practitioners for different conditions (for example, nephrology PCM for CKD plus primary-care CCM for multimorbidity), each with its own care plan.
• CCM with Remote Patient Monitoring (RPM). RPM (for example, home blood pressure cuffs) can be billed in the same month as CCM if all requirements are met and minutes are not double-counted. Many kidney programs combine monthly CCM coaching with RPM-driven alerts to tighten blood pressure control and improve medication titration.
• CCM and monthly End-Stage Renal Disease (ESRD) services. Once a patient starts dialysis, monthly ESRD services (CPT 90951–90970) generally cannot be billed in the same month as CCM due to overlapping scope. The “not yet on dialysis” window is where CCM is most often applied in nephrology.

Taken together, these pairing rules help teams design complementary workflows that improve outcomes while avoiding denials and double-counting.

Implementation at a glance

Here are some key points to consider when implementing CCM in a CKD context:

• Identify who benefits most. Patients with CKD plus hypertension and/or diabetes, rising albuminuria, recurrent AKI, medication complexity, or social barriers that derail follow-through are prime candidates.
• Stand up a kidney-aware script and checklist. Incorporate sodium goals, home blood pressure routines, medication side-effect prompts, lab due dates (eGFR/UACR), sick-day rules, and escalation thresholds.
• Wire in the nephrology relationship. Build closed-loop pathways so that abnormal results and red flags route to the right clinician quickly.
• Mind the rules. Ensure documented consent, a comprehensive, shareable electronic care plan, around-the-clock access and continuity, and clear practitioner oversight of clinical staff work.

A small, consistent cadence beats sporadic intensity. Start with a focused cohort, refine the playbook, and scale as your team builds momentum.

Ready to make the “between-visit” interval count for your kidney patients? Lara Health’s platform streamlines eligibility checks, prompts kidney-specific scripts, tracks labs and due dates, and documents time and care-plan updates automatically—so your team can focus on coaching and timely escalation. Book a demo with Lara Health and see how a kidney-aware CCM workflow elevates outcomes and prepares patients for smoother transitions if dialysis or transplant becomes necessary.

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FAQs

Who can bill CCM?

Physicians and other eligible practitioners (for example, nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives) may bill CCM for a given patient and month; only one practitioner may bill per month.

Does a patient need two conditions for CCM?

Yes. CCM requires at least two chronic conditions expected to last at least 12 months (or until death) that place the patient at significant risk. For many CKD patients, hypertension and/or diabetes meet this threshold alongside CKD.

Can we bill CCM and RPM in the same month?

Yes, if all service requirements are met and you do not double-count time. CCM minutes must reflect CCM scope; RPM minutes must reflect RPM scope.

Can we bill CCM and ESRD monthly dialysis services together?

No. CCM cannot be billed in the same calendar month as certain ESRD monthly services (CPT 90951–90970) due to overlapping comprehensive management.

What visit can start CCM?

If required, an initiating visit can be a comprehensive E/M, an Annual Wellness Visit (AWV), or an Initial Preventive Physical Examination (IPPE). Informed consent must be documented, and the care plan must be comprehensive and shareable.

Sources

Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Frequently Asked Questions. 2022.

U.S. Department of Health and Human Services (HHS). Telehealth.HHS.gov — Remote patient monitoring: Billing and reimbursement. 2024.

Centers for Medicare & Medicaid Services (CMS). Physician Fee Schedule resources. 2024–2025.

Centers for Disease Control and Prevention (CDC). Chronic Kidney Disease in the United States. 2023–2024.

Kidney Disease: Improving Global Outcomes (KDIGO). 2024 Clinical Practice Guideline for the Evaluation and Management of CKD. 2024.

American Diabetes Association (ADA). Standards of Care in Diabetes—2025: Chronic Kidney Disease and Risk Management. 2025.