CCM for pulmonary health: managing COPD and asthma through monthly care
Mrs. Taylor is a 74-year-old former smoker with chronic obstructive pulmonary disease (COPD). Despite a good relationship with her pulmonologist, most of her days are spent outside the clinic, struggling with breathlessness, worrying about flare-ups, and wondering if she’s using her inhaler correctly. Last winter, she landed in the emergency room after ignoring worsening symptoms for a week, believing it was “just a cold.” What if her care team had been checking in monthly—reviewing her symptoms, inhaler use, and making sure follow-up visits were scheduled? This is the type of gap that Chronic Care Management (CCM) is designed to close.
What is chronic care management
Chronic Care Management (CCM) is a Medicare-covered service that reimburses eligible practitioners for coordinating non–face-to-face care for patients with two or more chronic conditions expected to last at least 12 months (or until death) and that place the patient at significant risk of decline or exacerbation.
Eligible billing practitioners include physicians (MD/DO), nurse practitioners (NP), physician assistants (PA), certified nurse specialists (CNS), and certified nurse midwives (CNM). Limited-license practitioners, such as podiatrists, are not eligible.
CCM requires documented consent, a comprehensive electronic care plan, 24/7 access to urgent care, and monthly structured outreach.
Billing codes (CY2025):
CPT 99490: at least 20 minutes of clinical staff time directed by a physician or qualified health professional
CPT 99439: each additional 20 minutes
CPT 99487: complex CCM, at least 60 minutes with moderate/high complexity medical decision-making
CPT 99489: each additional 30 minutes of complex CCM
Why pulmonary patients need CCM
Respiratory diseases are among the most common chronic conditions in older adults. COPD alone affects over 16 million Americans, and asthma contributes to millions of ER visits every year. These conditions frequently coexist with cardiovascular disease, diabetes, or depression, making many patients ideal candidates for CCM.
The challenge is that most of the struggle happens outside the specialist’s office. Patients forget medications, miss pulmonary rehab sessions, or fail to recognize the warning signs of an exacerbation. Monthly CCM calls ensure someone is consistently checking in, reinforcing education, and keeping critical care activities from slipping through the cracks.
Interventions CCM delivers for COPD and asthma
A well-designed CCM program does more than ask a few generic questions. It builds respiratory health directly into the care plan and keeps the care team coordinated month after month. Typical interventions include:
Inhaler technique checks. Many patients misuse inhalers, reducing drug delivery and symptom control. CCM coordinators can review technique remotely and flag problems for correction.
Medication reconciliation. CCM teams verify adherence, monitor side effects, and check for drug interactions that may affect pulmonary medications.
Pulmonology follow-ups. Coordinators help patients keep appointments for spirometry, imaging, or specialist consults—rescheduling quickly if one is missed.
Pulmonary rehabilitation. Patients are connected with local or virtual rehab programs, reinforcing exercise tolerance and breathing strategies.
Smoking cessation support. CCM reinforces counseling, checks on nicotine replacement, and ensures patients know about available resources.
Symptom tracking. Monthly calls cover cough, sputum, wheeze, and shortness of breath. Early pattern recognition helps flag deterioration before it requires an ED visit.
Exacerbation action plans. Patients are reminded of their personalized action plan—when to use rescue inhalers, when to call the office, and when urgent care is necessary.
By integrating these elements into a single, documented plan, CCM ensures nothing is left to chance. Everyone on the team, from pulmonologist to primary care, sees the same coordinated roadmap.
How CCM prevents exacerbations and hospitalizations
Every COPD or asthma hospitalization is costly, stressful, and often accelerates long-term decline. Exacerbations can permanently reduce lung function, shorten life expectancy, and diminish independence. CCM provides a system for prevention:
- Earlier detection. Monthly outreach captures subtle symptom changes or medication lapses before they spiral into emergencies.
- Care continuity. Patients feel reassured knowing someone will check in regularly, reducing the sense of isolation between visits.
- Coordinated escalation. When concerning symptoms emerge, CCM workflows activate fast referrals to pulmonology, urgent care, or emergency services.
Research from COPD care coordination and asthma management programs suggests that structured, ongoing interventions reduce hospitalizations and improve medication adherence. While evidence is still evolving, the logic of monthly touchpoints aligns with guideline-based prevention strategies.
Implementation strategy
Starting CCM for pulmonary patients doesn’t require overhauling the clinic overnight. Primary care and pulmonology practices can begin with a subset of high-risk patients and scale from there:
- Identify eligible patients. COPD or asthma patients with at least one other chronic condition such as hypertension, diabetes, or CKD.
- Obtain consent. Explain the program, what monthly calls include, and how billing works.
- Develop care plans. Include inhaler use, rehab referrals, smoking cessation, and specialist coordination alongside other chronic disease goals.
- Assign coordinators. Nurses or MAs (supported by CCM software) conduct monthly outreach and log time.
- Close the loop. Abnormal findings are escalated to supervising providers without delay.
ROI and financial impact
CCM is both clinically impactful and financially sustainable:
- Predictable revenue. Each enrolled patient generates ~$62–$170 per month depending on complexity and time, according to the 2025 Physician Fee Schedule. For 100 COPD/asthma patients, that translates to six-figure annual revenue.
- Reduced hospitalizations. Avoiding even a handful of inpatient stays more than covers program costs, while supporting value-based care metrics.
Common pitfalls and how to avoid them
CCM programs sometimes falter when they are treated as compliance tasks rather than patient-centered services. Pitfalls include:
- Generic scripts. Asking vague questions that don’t uncover real issues.
- Siloed communication. Pulmonologists not being looped into updates, leading to fragmented care.
- Incomplete documentation. Missing time logs or outdated care plans that fail audit standards.
The solution: use structured, condition-specific scripts, share updates across the care team, and track time and interventions rigorously. Lara Health’s CCM platform embeds these safeguards into everyday workflows.
Compliance and audit readiness
CMS requires that every CCM program include documented patient consent, a comprehensive shareable care plan, accurate time logs, and 24/7 access for urgent issues. For pulmonary patients, that means ensuring that every inhaler review, symptom check, and referral is not just done, but properly recorded.
Lara Health simplifies this process by embedding COPD- and asthma-specific prompts into care plans, automating time tracking, and streamlining documentation so practices remain audit-ready while focusing on care.
Conclusion
CCM closes the gaps that often leave COPD and asthma patients vulnerable between visits. Through inhaler checks, symptom tracking, smoking cessation support, and proactive coordination, practices can reduce exacerbations, improve quality of life, and stabilize patients at home.
Every monthly CCM call is an opportunity to help a patient breathe easier. Learn more about Chronic Care Management with Lara Health to see how effortless pulmonary care coordination can be with the right tools and workflows.
FAQs
Can pulmonologists bill CCM directly?
Yes. Pulmonologists, primary care physicians, NPs, PAs, CNSs, and CNMs may bill CCM if requirements are met.
Does a patient with only COPD qualify for CCM?
No. Patients must have at least two chronic conditions. A patient with COPD plus diabetes, hypertension, or another chronic disease would qualify.
What’s the difference between CCM and Principal Care Management (PCM)?
CCM requires management of two or more chronic conditions. PCM is designed for patients with a single complex chronic condition that needs intensive support.
Can CCM and RPM be billed in the same month?
Yes—if billing requirements are met and the same minutes of care are not double-counted.
How often should inhaler technique be checked?
Inhaler technique should be reviewed at least annually in clinic. CCM allows monthly reinforcement and troubleshooting to improve medication delivery and outcomes.
Sources
CMS, Chronic Care Management Services, MLN909188, 2025.
CDC, COPD Data and Statistics, 2024.
CMS, CY2025 Physician Fee Schedule Final Rule.
