How to Choose the Best CCM Platform: Key Factors to Consider

Dr. Patel runs a busy primary care clinic with a panel full of patients living with diabetes, heart failure, COPD, and other long-term conditions. She knows Chronic Care Management (CCM) could help keep those patients healthier between office visits — and generate a steady stream of Medicare reimbursement. But her last attempt, using a generic task tracker, ended in frustration: staff found the software clunky, patient calls went undocumented, claims stalled in the clearinghouse, and many patients quietly disappeared from the roster.

This time, Dr. Patel wants more than a vendor demo. She wants proof that the platform will be easy for her staff, give her oversight, track meaningful results, align with her interests, and stand up under Medicare’s rules.

Here’s what to look for when evaluating a CCM solution that will deliver results not just at launch, but year after year.

1. Ease of Use for Clinical Staff

If the platform slows your team down, your CCM program will struggle. Care coordinators and nurses need to navigate it quickly, log activities without hunting through menus, and pull up care plans while on the phone with patients.

Example:

At a suburban group practice, care managers fought with a CCM portal that required six clicks to log a single blood pressure review. Over time, entries were skipped, documentation fell behind, and billable minutes were lost.

Ease of use directly supports compliance — the less friction, the more likely staff will document all required elements, from monthly time thresholds to care plan updates. AMA research identifies workflow fit and efficiency as major adoption drivers for digital tools. Lara Health’s CCM interface puts patient information, care plans, and time tracking on a single screen, minimizing clicks so documentation happens in real time.

‍

2. Availability of Outsourcing Solutions

Not every practice can dedicate staff to CCM full-time. A platform that offers integrated, HIPAA-compliant outsourcing — with trained care coordinators following your protocols — can help you launch or scale without overloading your team.

Example:

A two-physician clinic wanted to start CCM but had no bandwidth. They partnered with a platform’s care coordination service, which handled monthly calls and documentation while the clinic retained full review and approval rights.

CMS permits CCM to be furnished by clinical staff under general supervision of the billing practitioner, “incident to” their services. Staff can be employees or contracted personnel, making outsourcing viable if oversight and documentation are in place. Lara Health supports a hybrid model: your staff, Lara Health’s care coordination team, or both — all using the same tools, workflows, and compliance safeguards.

3. Ability for the Provider to Supervise and Stay in Control

Even with delegated staff or outsourced help, the billing practitioner is responsible for CCM services. The platform must give providers easy visibility into all patient interactions, care plan changes, and time logs.

Example:

Dr. Chen uses her supervisory dashboard every Friday to review care plans, check logged minutes, and flag overdue follow-ups. This regular oversight keeps her confident in both care quality and compliance.

CCM codes 99487, 99489, 99490, and 99439 are furnished under general supervision in the Physician Fee Schedule, meaning the practitioner must provide overall direction and control — without needing to be physically present. Lara Health’s provider dashboard consolidates key compliance and performance metrics in one view, enabling quick reviews without micromanaging.

4. Monitor Effective Results — With Claims Actually Getting Paid

A CCM platform’s value is only realized when services translate into paid claims. That means tracking the full revenue cycle — from time logging to claim submission to remittance.

Example:

One clinic discovered that 15% of its CCM claims were denied for missing consent or insufficient time. Their new platform flagged these gaps before submission, cutting denials to under 2%.

An initiating visit is required for new or not-seen-within-1-year patients, along with documented informed consent before billing [1]. Time thresholds must be met for each code: 99490 (20 min), +99439 (additional 20 min), 99487 (60 min with moderate/high MDM), +99489 (additional 30 min), 99491/ +99437 (personally performed by the practitioner). Lara Health integrates billing compliance checks directly into the workflow, flagging missing consent, initiating visits, or insufficient time before a claim is ever sent.

5. Track Real Engagement — Are Patients Being Followed Every Month?

Enrollment is meaningless without consistent monthly contact. The platform should highlight missed months, track completion rates, and help staff re-engage patients.

Example:

A cardiology clinic thought its CCM program was reaching 90% of patients. The platform’s report showed that only 68% had completed their monthly calls, prompting targeted outreach and a staffing change.

Only one practitioner may bill CCM for a patient per calendar month, and time may not be counted toward more than one billed service. Missed contact means missed reimbursement and potentially compromised care. Lara Health automatically tracks monthly engagement and sends alerts for overdue patients, helping practices maintain both compliance and quality.

6. Fee Structure — Are the Vendor’s Interests Aligned With Yours?

Some vendors charge flat per-patient fees whether or not patients are contacted or claims are paid. Others use performance-based pricing that ties their incentives to your program’s success.

Example:

A large practice moved from a flat-fee vendor to one with a per-completed-service fee. Their new partner offered more training and active support because their own revenue depended on successful CCM delivery.

Operational note:

Use your local MAC or national PFS rates to model revenue: Monthly CCM revenue ≈ (99490 rate × 1 if ≥20 min) + (99439 rate × additional units) + (99487/99489 if complex CCM criteria met) + (99491/99437 if personally performed by practitioner). Lara Health offers pricing models tied to program performance, ensuring our success depends on yours.

Implementation Strategy

Start with a pilot group (20–40 patients) to refine enrollment scripts, documentation templates, and workflows. Train staff not just on the software but on patient communication techniques. Track key KPIs monthly — enrollment, engagement, minutes logged, claim acceptance, and net reimbursement — and scale only once processes are stable.

‍

Common Pitfalls — and How to Avoid Them

Ignoring ease of use: If staff find the system cumbersome, documentation will lag, leading to compliance risk and missed revenue.

No oversight mechanisms: Without dashboards and alerts, providers can lose visibility into whether monthly requirements are being met.

Vendor misalignment: A vendor paid regardless of results has little incentive to help you improve. Align your agreements to completed, compliant services.

‍

Compliance and Audit Readiness

The right platform captures every CMS-required element — initiating visit, informed consent, comprehensive care plan, monthly time thresholds, and concurrency compliance — and produces them instantly in an audit. CMS’s concurrent billing rules prohibit double-counting time and outline which services CCM can and cannot be billed with. Lara Health maps every recorded action to CPT requirements, flags compliance gaps in real time, and supports the RHC/FQHC transition from G0511 to individual codes through Sept 30, 2025.

‍

Conclusions

A CCM program thrives when the platform is easy for staff, supports outsourcing when needed, keeps providers in control, ensures claims get paid, tracks true patient engagement, and aligns vendor incentives with your goals. With these factors in place, CCM moves from theory to a sustainable, high-impact service.

Ready to run a CCM program that lasts? Learn more about chronic care management (CCM) with Lara Health and see how we align tools, workflows, and incentives for your long-term success.

‍

FAQs

Which CPT codes are used for CCM, and how much time is required?

99490 (20 min, clinical staff under general supervision), +99439 (additional 20 min), 99487 (60 min with moderate/high MDM), +99489 (additional 30 min), 99491 (30 min personally by practitioner), +99437 (additional 30 min personally by practitioner).

Do I need consent and an initiating visit?

Yes. Obtain documented informed consent before billing. For new or not-seen-in-1-year patients, conduct an initiating visit (E/M, AWV, or IPPE).

Can multiple clinicians bill CCM for the same patient in the same month?

No. Only one practitioner may bill CCM for a patient per calendar month.

Can CCM be billed with RPM or TCM?

Yes, but time cannot be counted for more than one service, and some concurrent service restrictions apply.

What changed for RHCs/FQHCs in 2025?

CMS is transitioning RHCs/FQHCs from G0511 to individual codes, with a transition period through Sept 30, 2025.

‍

References

CMS — Chronic Care Management Services, MLN909188 (June 2025)

CMS — Information for Rural Health Clinics, MLN006398 (July 2025)

CMS — FQHC Center, CY2025 Billing Guidance (2025)

CMS — CY2025 Physician Fee Schedule Final Rule Fact Sheet (Nov 2024)

AMA — AMA Digital Health Care 2022 Study Findings (Sept 2022)

AMA — AMA Digital Health Study (PDF) (2022)