Chronic Care Management for Rheumatologists: Why It’s Time to Make CCM Part of Your Patient Care

Rheumatology focuses on diagnosing and managing hundreds of chronic, inflammatory, and musculoskeletal conditions. These diseases often cause persistent pain, inflammation, fatigue, and reduced mobility, disrupting daily life for years. From rheumatoid arthritis to lupus, osteoporosis to gout, rheumatologists care for patients with complex, lifelong needs that demand attention between visits. Many of these patients meet Medicare’s criteria for Chronic Care Management (CCM): they have two or more chronic conditions expected to last at least 12 months (or until death) and face significant risk if their illnesses are not actively managed. CCM requires an initiating visit, documented consent, an electronic, shareable care plan, and 24/7 access to address urgent needs.

Much of what keeps rheumatology patients well—medication follow‑up, lab reviews, self‑management coaching, and coordination across specialists—happens between office visits. Historically, that work was uncompensated. CCM changes that by reimbursing structured, documented non–face‑to‑face care that patients rely on.

Common Chronic Conditions Managed by Rheumatologists

Rheumatology spans an exceptionally broad spectrum. The list below is not exhaustive but illustrates how often patients carry multiple conditions that require ongoing coordination.

• Arthritis: Rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and osteoarthritis.
• Autoimmune Diseases: Lupus, scleroderma, and myositis.
• Metabolic Bone Disorders: Osteoporosis and other bone‑weakening conditions.
• Crystal Arthropathies: Gout and pseudogout caused by crystal buildup in joints.
• Vasculitis: Inflammation of blood vessels affecting organs and tissues.
• Musculoskeletal Infections: Infections impacting muscles, bones, and joints.
• Fibromyalgia Syndrome: Widespread musculoskeletal pain, fatigue, and cognitive difficulties.
• Sjögren’s Syndrome: Autoimmune disease affecting moisture‑producing glands.
• Polymyalgia Rheumatica: Muscle pain and stiffness, especially in the shoulders, neck, and hips.
• Tendon and Muscle Conditions: Tendonitis, myopathy, and other soft‑tissue disorders.
  

The American College of Rheumatology (ACR) catalogs a wide range of rheumatic diseases, underscoring how common multi‑morbid, long‑term management is in this specialty.

Why CCM Is a Game‑Changer for Rheumatology Practices

Here are four key reasons rheumatologyis a perfect match for chronic care management (CCM):

1. Better Outcomes for Complex Patients

Patients with chronic rheumatic diseases need consistent monitoring to prevent flares, minimize disability, and detect complications early. Within CCM, your team can check medication adherence (e.g., DMARDs, biologics) monthly, monitor labs and imaging results in real-time, identify comorbidities like cardiovascular disease or osteoporosis earlier, provide proactive guidance on lifestyle and self-management. This leads to fewer ER visits, improved mobility, and higher patient satisfaction. Across Medicare populations, CMS has reported that CCM participation is associated with nearly a 5% reduction in hospitalizations and a 2.3% reduction in emergency department visits, a signal consistent with more reliable follow‑up and care coordination.

2. Recurring Revenue Without Adding Clinic Visits

CMS introduced Chronic Care Management to compensate providers for the non-face-to-face care they already deliver to patients with two or more chronic conditions — which applies to nearly every rheumatology patient.

Typical reimbursement: $62–$150 per patient, per month, depending on complexity and time spent. That’s $744–$1,800 per patient per year in predictable revenue. For a panel of 200 qualifying patients, that’s six figures in annual revenue, without adding more in-office appointments.

CCM can also be complemented by other preventative care programs such as Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Principal Care Management (PCM), and other revenue generating care programs. When layered together, these programs can significantly increase per-patient revenue while further improving patient outcomes and engagement.

CCM can also be complemented by other preventative care programs such as Remote Patient Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Principal Care Management (PCM), and other revenue generating care programs. When layered together, these programs can significantly increase per-patient revenue while further improving patient outcomes and engagement. Use current MLN/PFS guidance before combining services.

3. Streamlined Communication Across Care Teams

Rheumatology patients often have care plans that touch cardiology, nephrology, dermatology, endocrinology, and primary care. CCM’s shareable electronic care plan and monthly contacts make medication changes visible across the team and keep messages to patients consistent. Without structured updates, important details get missed.

CCM ensures:

• Care plans are documented and shared
• Medication changes are coordinated between providers
• Patients receive consistent messages from all members of their healthcare team
  

This reduces duplicative testing, prevents conflicting treatments, and improves safety.

4. Minimal Disruption to physician's Workflow

The best CCM platforms, like Lara Health, integrate with your EHR seamlessly, flag eligible patients, and automate documentation. Your team can complete CCM activities in minutes, and the system ensures compliance with CMS billing requirements.

In short: the best CCM platforms organize and streamline the work you already do, and finally ensure you get paid for it.

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Why Rheumatology Is Perfectly Suited for CCM?

Several factors contribute to making rheumatology a perfect match for CCM:

• Almost all patients qualify (2+ chronic conditions is the norm).
• The care is already happening. CCM formalizes and reimburses it.
• It improves disease management and reduces flare frequency.
• It strengthens patient engagement between visits.
• It creates a sustainable revenue stream in a specialty with high follow-up demands.

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The Bottom Line

Rheumatologists already act as medical detectives, piecing together symptoms, labs, and imaging to manage complex diseases. But the work doesn’t stop when the appointment ends, and neither should the support patients receive. CCM turns essential between‑visit care into a structured, billable service that benefits both patients and your practice by enabling:

• Continuous, proactive patient support;
• Reductions in avoidable utilization observed among CCM cohorts in Medicare data;
• A better patient experience through consistent follow‑up; and
• A recognized payment pathway for non–face‑to‑face care (with market‑specific rates set via the PFS).

Concurrency reminder: For the same patient and month, you may pair CCM with RPM or RTM (not both), and you may not double‑count time toward multiple billed services. Validate PCM/CCM combinations for the same practitioner and month against current CMS materials before implementation. Learn more about how CCM works with Lara Health.

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Sources

Centers for Medicare & Medicaid Services (CMS). MLN909188 — Chronic Care Management Services (Booklet). June 2025.

Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Toolkit / CCM at‑a‑Glance. 2017.

Centers for Medicare & Medicaid Services (CMS). Physician Fee Schedule (PFS) — CY2025 Final Rule Fact Sheet; PFS Payment Resources. 2024–2025.

American College of Rheumatology (ACR). Diseases & Conditions. 2025.

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