Is Chronic Care Management (CCM) a Good Fit For Your Practice? Here’s How to Know.

At Riverside Family Clinic (not the actual name), the phones never stop ringing. The team (two physicians, a nurse practitioner, and three medical assistants) cares deeply about their 5,000 patients. They pride themselves on knowing every diabetic by name, calling to check in after hospitalizations, and helping patients navigate medication refills or lab scheduling. Their patients love them. But behind the dedication lies exhaustion. The doctors spend hours after clinic finishing charts and returning calls. Nurses coordinate with pharmacies, home health, and specialists, all unpaid time.

The clinic’s mission is strong, but margins are thin. Reimbursement rates are stagnant, overhead costs are rising, and everyone feels the strain.

As the clinic’s manager put it: “We’re doing more for our patients than ever, but somehow getting paid less for it. If only we could be reimbursed for all the work we do between visits.”

That “if only” is exactly where Chronic Care Management (CCM) changes everything.

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Chronic Care Management: the missing link between effort and income

CCM turns what has always been invisible labor (the coordination, follow-up, and preventive outreach that happens after a visit) into structured, reimbursable care. It gives practices a framework to support patients with two or more chronic conditions while compensating them for the real work of keeping those patients healthy between appointments. For clinics like Riverside, CCM doesn’t just mean more revenue: it means sustainability, recognition, and relief. It turns dedication into data, effort into structure, and care into a financially viable model.

For organizations that have long operated in a reactive, visit-based world, CCM provides something increasingly rare in modern healthcare: a way to deliver higher quality care while stabilizing operations, economic results, and improving team morale.

But CCM isn’t a fit for every practice. Some clinics are perfectly positioned to thrive, while others may be better served by complementary programs like Remote Patient Monitoring (RPM), Principal Care Management (PCM), or Behavioral Health Integration (BHI).

This guide breaks down which practices benefit most from CCM, and how those that adopt it can build a durable foundation for both better care and better business.

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Why CCM matters

At its heart, CCM creates structure, sustainability, and equity. It gives care teams a reliable framework to manage patients with two or more chronic conditions systematically, instead of responding only when problems arise. CCM code family (CY 2025):

• 99490 - Non-complex CCM: clinical staff time (≥ 20 min/month) under general supervision.
• 99439 - Add-on for each additional 20 minutes of clinical staff time (same month).
• 99487/99489 - Complex CCM (clinical staff: 60 + 30 minutes) requiring moderate/high medical decision-making.
• 99491 - Provider-time CCM: personally furnished by a physician/QHP (≥ 30 min/month).
• 99437 - Add-on for each additional 30 minutes of provider time.
  

Why it matters:

• Better outcomes: Monthly contact improves adherence, flags issues early, and reduces ER visits.
• Operational efficiency: Organized workflows eliminate ad hoc calls, refill chaos, and scattered chart updates.
• Financial stability: Recurring, per-member-per-month reimbursement (typically $62–$80 [VALIDATE LOCALLY]) stabilizes cash flow.
• Provider satisfaction: Less reactive work, more meaningful engagement, and recognition for time spent outside the exam room.
  

Practices managing hundreds or thousands of chronically ill patients can generate up to $700,000 in recurring annual revenue per 1,000 enrolled patients, while improving patient satisfaction and reducing avoidable hospitalizations. (Note: All financial examples are illustrative and vary by payer, region, and code mix. Verify reimbursement rates using the CMS Physician Fee Schedule Look-Up Tool.)

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Primary care practices: the natural fit

If there’s one setting where Chronic Care Management (CCM) was designed to thrive, it’s primary care. Family medicine, internal medicine, and geriatric clinics are the front line of chronic disease management in America. Every day, they balance prevention, acute care, and long-term management, often for the same patient, in the same visit. They coordinate across specialists, reconcile medications, field triage calls, and review labs long after the appointment ends.

And for most clinics, that crucial between-visit work has always been unpaid.

Why primary care is built for CCM

Primary care practices already have the infrastructure, relationships, and clinical mission that CCM formalizes and rewards:

• Longitudinal relationships: Primary care clinicians know their patients over years, not visits. They manage not just one condition, but the complex interplay of multiple chronic diseases, often coordinating with several specialists.
• High eligibility rates: A significant portion of Medicare panels meet CCM criteria (two or more chronic conditions expected to last at least 12 months). In many practices, 60–70% of the population qualifies.
• Care teams ready to act: RNs, MAs, and care coordinators already perform many CCM activities (follow-up calls, medication reviews, lab tracking) they just need a billing framework and documentation tools.
• Preventive alignment: Primary care thrives on prevention, and CCM extends that mission beyond the walls of the clinic.
  

Simply put, CCM doesn’t change how primary care practices care for patients, it changes how they’re recognized and reimbursed for that care.

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A day in the life before and after CCM

Before implementing CCM, most primary care clinics look like this: Phones ringing nonstop with refill requests and “quick questions.” Nurses staying late to document outreach or check on complex patients. Physicians squeezed by rising costs and declining reimbursements.

After CCM: Every monthly check-in is logged and billable. Medication reviews, care coordination, and social determinant assessments are tracked automatically. Patients with hypertension, diabetes, or COPD get proactive follow-up instead of waiting for crises. The clinic gains predictable revenue for the same work that once stretched its staff thin.

“We didn’t have to reinvent the wheel,” one internal medicine physician shared after launching CCM. “We were already doing the work, now it’s structured, tracked, and sustainable.”

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How CCM transforms primary care operations

CCM brings three major operational benefits to primary care:

1. Order replaces chaos:
2. Instead of reacting to patient calls, the team follows a structured outreach schedule. Every patient has a monthly touchpoint, tracked through templates or a dedicated care-management platform like Lara Health.
3. Delegation becomes efficient:
4. Clinical staff can handle most CCM activities (checking vitals, confirming medication adherence, updating care plans) under general supervision. That means physicians spend less time chasing administrative details and more time making clinical decisions.
5. Revenue stabilizes:With average per-member-per-month reimbursement between $62–$80, even small panels make a big difference.
   • 500 patients enrolled = ≈ $372,000–$480,000/year
   • 1,000 patients enrolled = ≈ $744,000–$960,000/year
   • This steady cash flow offsets declining fee-for-service revenue and supports hiring additional nursing or care-coordination staff.

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Why CCM restores purpose to primary care

Primary care has always been about relationships, knowing patients deeply, managing complexity, and preventing what can be prevented. CCM rewards exactly that.
It lets clinicians focus on what matters most:

• Maintaining consistent contact with at-risk patients.
• Guiding patients through complex regimens and multiple specialists.
• Building trust that keeps patients engaged and healthier over time.
  

For providers exhausted by endless reactive work, CCM offers something both practical and restorative, a way to turn care into sustainability and compassion into measurable success.

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Specialty practices: hidden opportunities for CCM

While primary care is the natural home for Chronic Care Management (CCM), specialty practices stand to gain just as much, and in some cases, even more.

Many specialists already spend hours managing complex patients outside the exam room: reviewing labs, adjusting medications, coordinating with other providers, and fielding phone calls from patients who need reassurance or clarification. These are all CCM-eligible activities, they just haven’t been structured, tracked, or reimbursed.

CCM provides specialists a way to capture the value of the care they’re already delivering while improving continuity, patient engagement, and outcomes.

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Why specialists benefit from CCM

For specialists, CCM accomplishes three key goals:

1. Reduces fragmentation: Many chronic patients see multiple specialists. CCM allows each participating provider to define their role and document coordination clearly.
2. Builds consistent follow-up: Structured monthly contact improves adherence to treatment plans and reduces preventable exacerbations.
3. Creates new recurring revenue: Each enrolled patient represents a reimbursable monthly care-management relationship — often supplementing lower-margin procedures or office visits.
   

The average reimbursement per patient per month (PMPM) remains the same across practice types (roughly $62–$80) but because specialty patients are often higher acuity, the clinical impact per CCM relationship is even greater.

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Best-fit specialties for CCM

Some specialties are especially well-positioned to succeed with CCM because their patient populations are inherently chronic, their conditions require frequent adjustments, and care continuity is critical:

1. Cardiology: preventing readmissions and improving control

Cardiologists routinely manage high-risk patients with hypertension, coronary artery disease, heart failure, and atrial fibrillation — all prime candidates for CCM.

• Operational example: A cardiology group enrolls 600 patients with hypertension or CHF. Using Lara Health’s platform, RNs document medication adherence calls, home BP follow-ups, and coordination with primary care.
• Integration with RPM: Each patient is provided a cellular blood pressure cuff and scale for fluid monitoring. RPM data flows directly into the CCM dashboard, where staff identify outliers and escalate to the physician.
• Results: After six months, the group reports a 25% reduction in CHF-related hospitalizations and over $450,000 in annual CCM/RPM revenue.
  

2. Endocrinology: bridging the gap between visits

Endocrinologists manage patients with diabetes, thyroid disorders, and metabolic syndrome, conditions that demand consistent oversight and patient engagement.

• Operational example: A practice enrolls 400 patients in CCM, assigning a care coordinator to review logs, track lab compliance, and handle dietary or medication adjustments.
• Integration with RPM: Patients with diabetes use connected glucose monitors. Data feeds into Lara Health, which flags abnormal readings for follow-up.
• Results: Within a year, the clinic achieves a 0.8% average reduction in A1c, improved medication adherence, and approximately $300,000 in new recurring revenue.
  

CCM formalizes what endocrinologists already do every day (follow-up calls, lab review, medication titration) but with documentation, time capture, and reimbursement baked in.‍

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3. Pulmonology: continuity for COPD and asthma patients‍

Pulmonologists treat patients prone to exacerbations and costly hospitalizations. CCM ensures these patients are followed consistently and have rapid access to the care team.

• Integration example: COPD patients enrolled in CCM receive monthly calls focused on symptom check-ins, inhaler adherence, and trigger management. Those also enrolled in RPM use pulse oximeters to track oxygen levels.
• Outcomes: Improved control of COPD symptoms, reduced readmission rates, and a steady revenue stream to offset the high administrative workload associated with chronic respiratory care.

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4. Nephrology: managing progression and coordination

For nephrologists managing CKD (stages 3–5), CCM enables more effective care coordination with dietitians, primary care, and dialysis providers.

• Operational benefit: Early interventions (such as medication adjustments or referral to nutrition counseling) are documented as CCM activities and billed monthly.
• Impact: Patients stay stable longer, delaying progression to dialysis while the clinic gains predictable revenue that supports multidisciplinary coordination.

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How specialists integrate CCM with other programs

Specialty practices achieve the strongest results when they combine CCM with other remote care programs, especially RPM and PCM.

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Financial upside for specialists

Even smaller specialist panels can generate significant recurring revenue. For example:

• 300 enrolled CCM patients × $70 PMPM × 12 months = $252,000 annually.
• Add RPM ($50 PMPM) for 200 of those patients = +$120,000 more.
• Total potential: ≈ $370,000/year, for work the care team is already doing.
  

Beyond revenue, specialists report lower no-show rates, improved quality scores, and greater patient loyalty once CCM is in place.

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Why CCM gives specialists a competitive advantage

CCM not only improves patient care, it enhances practice reputation and sustainability.

• Referring providers trust you more: Primary care doctors see better results from their shared patients.
• Patients engage longer: Monthly contact builds trust and loyalty.
• Insurers notice performance: Reduced utilization and better outcomes improve contracting power in value-based agreements.
  

Specialists who adopt CCM early position themselves as leaders in coordinated, data-driven, patient-first care — and they get paid for it.

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Practices that may not be ideal for CCM

Some clinics, depending on their patient mix, care model, or staffing resources, may find that CCM doesn’t naturally align with how they deliver care.
And that’s okay. The reality is that not every practice should start with CCM, but every practice can, and should, find a path into remote care management. The key is understanding which program best matches your workflow and patient relationships, and partnering with a platform that supports the full spectrum of remote care services  (from CCM to PCM, RPM, RTM, TCM, and even APCM) so your care model can evolve as your practice grows.
Understanding where CCM fits best (and where other programs make more sense) ensures that each practice invests its energy where it can achieve maximum impact.

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When CCM may not be the best match

1. Surgical and procedural practices: short-term focus, episodic relationships. Specialties like orthopedics, ophthalmology, and general surgery focus primarily on episodes of care — procedures, recoveries, and discharges. Once a patient heals, the relationship typically ends, making the longitudinal engagement CCM requires difficult to sustain.

Better fit:

• Remote Therapeutic Monitoring (RTM) (CPT 98975–98981) allows surgical and rehab practices to bill for therapy adherence and recovery progress over 30-day periods.
• RTM devices can track metrics like pain, motion, or respiratory patterns, ideal for short-term rehabilitation and post-operative follow-up.
  

Example:

An orthopedic practice in Arizona used RTM for knee replacement recovery, tracking mobility and pain through wearable sensors. They billed monthly under RTM, improved patient satisfaction scores, and reduced recheck appointments, all without the administrative burden of CCM.

2. Acute and urgent-care clinics: minimal continuity

Urgent-care and acute-care centers are built for immediate, episodic needs, infections, injuries, or acute flare-ups. Because they don’t maintain ongoing relationships with patients, CCM’s recurring engagement model doesn’t fit well.

Better fit:

• Transitional Care Management (TCM) (99495–99496) supports coordination after hospital discharge, where short-term follow-up is critical.
• TCM allows clinics to connect discharged patients to timely appointments, reconcile medications, and prevent readmissions, within a 30-day window.
  

Example:

A hybrid urgent-care clinic in Michigan built a TCM service line with nearby hospitals. Their NPs contacted patients within 48 hours of discharge and coordinated follow-up visits. Within a year, they cut readmissions and generated impactful annual TCM revenue.

3. Behavioral health practices: better served by integration models

Behavioral health providers deliver high-frequency, specialized care that aligns better with Behavioral Health Integration (BHI) or the Collaborative Care Model (CoCM) than traditional CCM.

These programs, BHI (CPT 99484) and CoCM (G0512 for RHCs/FQHCs), reimburse for care coordination between primary and behavioral health providers, ensuring patients receive holistic, integrated treatment.

Why BHI and CoCM work better:

• They align with behavioral health workflows (frequent follow-up, collaborative planning, and measurement-based outcomes).
• They support shared care between primary and behavioral teams without requiring a CCM-level administrative burden.
  

Example:

A family medicine clinic in Illinois integrated a BHI program alongside CCM. Behavioral health coordinators participated in care-plan updates for diabetic and hypertensive patients, improving both depression screening rates and A1c outcomes.

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The right program for the right practice

Every practice delivers care differently. The question isn’t whether remote care fits, it’s which version of it fits best. Because CCM may not be the perfect fit for every practice, it’s vital to partner with a platform that offers comprehensive coverage across the entire "alphabet soup" of remote care programs, not just one.

Lara Health is that platform. It supports billing for more than 55 CPT codes across major CMS remote care programs including CCM, RPM, RTM, TCM, PCM, and APCM in a single, integrated environment. That means whether your practice starts small with PCM, adds RPM for continuous monitoring, or grows into full CCM and APCM models, Lara Health scales with you, does not have a bias towards which program you would like to implement, and can help maximize the success of your remote care initiative by combining multiple programs in one single platform

Key advantages of Lara Health’s unified platform:

• All-in-one coverage: Manage every remote-care program from a single dashboard.
• Dynamic growth: Start with one program, layer in others as your capacity expands.
• Automated compliance: Built-in documentation, consent, and supervision prompts for each program type.
• Unified reporting: Consolidated analytics to track outcomes, minutes, and revenue across all programs.
• Future-proof flexibility: As CMS adds new codes or modifies requirements, Lara Health updates automatically, so you always stay compliant.
  

Even if CCM isn’t the right entry point today, Lara Health ensures your practice can still deliver and bill for remote care effectively, now and as your patient population evolves.

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The ideal fit: clinics that integrate multiple programs

The clinics that see the biggest transformation from remote care aren’t the ones running just a single program like Chronic Care Management (CCM): they’re the ones that integrate multiple care-management models into a unified strategy.

Why? Because chronic care isn’t one-dimensional. A patient doesn’t just have diabetes; they also have hypertension, anxiety, and mobility challenges after a hospital stay. When a practice layers programs like CCM, PCM, RPM, RTM, TCM, and APCM, it builds a continuous care loop that covers every phase of the patient journey, from prevention to post-discharge recovery. Integrated programs create stronger outcomes for patients, more efficient workflows for staff, and a financial foundation that allows practices to reinvest in care quality and innovation.

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The power of multi-program integration

Each CMS remote-care program is powerful on its own, but when combined, their impact multiplies:

• CCM (Chronic Care Management) provides monthly coordination for patients with two or more chronic conditions.
• PCM (Principal Care Management) supports focused management for patients with a single serious chronic condition, often managed by specialists.
• RPM (Remote Patient Monitoring) adds real-time physiologic data (e.g. blood pressure, glucose, weight, oxygen levels) that enable early intervention.
• RTM (Remote Therapeutic Monitoring) tracks therapy adherence and recovery progress for musculoskeletal or respiratory conditions.
• TCM (Transitional Care Management) bridges the critical 30 days post-discharge, preventing costly readmissions.
• APCM (Advanced Primary Care Management) expands beyond chronic care to encompass preventive, population-wide primary care coordination.
  

When these programs are combined under one platform, clinics can manage patients proactively across every care touchpoint.

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Financial sustainability through diversification

Just like investment portfolios, healthcare operations thrive on diversification. Relying on a single revenue stream leaves clinics vulnerable to seasonal fluctuations and payer changes. Integrated care programs create predictable, multi-channel revenue while improving population health outcomes.

By blending multiple programs, practices unlock revenue resilience: if one reimbursement model fluctuates, others balance the financial equation.

Integrating multiple remote-care programs can sound complicated, but with Lara Health, it’s seamless.

Lara Health is the only platform built to operationalize the entire alphabet soup of remote care programs (CCM, RPM, RTM, TCM, PCM, and APCM) in one compliant system.

Here’s how Lara Health simplifies it:

• Unified workflows: Manage all programs through one intuitive dashboard with unified patient records and care timelines.
• Automated documentation: Every call, device reading, or outreach activity is logged and attributed to the correct CPT or HCPCS code.
• Cross-program compliance: The system prevents time overlap between CCM, RPM, and PCM to keep billing fully CMS-compliant.
• Smart patient segmentation: Automatically identifies which patients qualify for which program and flags overlap opportunities (e.g., PCM → CCM, TCM → CCM).
• Consolidated reporting: Track quality metrics, patient engagement, and revenue across all programs from a single analytics dashboard.
  

One of the biggest misconceptions about remote-care programs is that they require large teams or dedicated departments. Lara Health eliminates that barrier by providing staffing flexibility for every practice size and structure: with the right partner, resource availability is no longer a barrier.

Whether your team is fully staffed or stretched thin, Lara Health adapts to your needs:

1. Fully in-house model

For larger practices or ACOs with existing care coordinators:

• Lara Health integrates with your EHR, automates patient identification, and tracks staff time for billing.
• Your team maintains full control, Lara Health provides the technology backbone and compliance infrastructure.
  

2. Hybrid support model

For medium-sized clinics balancing staff capacity and patient demand:

• Lara Health’s Virtual Care Managers, are licensed, experienced, trained to follow your workflows, and US-based: they work side-by-side with your team.
• They handle overflow outreach, data review, or care-plan documentation, ensuring no patient falls through the cracks.
  

3. Fully outsourced virtual care model

For small or resource-limited practices:

• Lara Health provides a complete virtual care team ( licensed, US-based RNs, MAs, and care coordinators) who operate as an extension of your clinic.
• They follow your protocols, document in your system, and report back to your providers for supervision.
  

No matter which model you choose, Lara Health ensures the same compliance, continuity, and care quality.

The multiplier effect: better care, stronger economics

When clinics integrate multiple programs under Lara Health’s unified platform, the results compound:

• Patients receive continuous, coordinated care that feels personal and preventive.
• Providers regain control of their time while maintaining clinical oversight.
• Staff experience less burnout thanks to automation and clear workflows.
• The practice gains stable, recurring revenue across multiple service lines.
  

Integrated remote care doesn’t just make practices more profitable, it makes them more resilient, data-driven, and aligned with the future of value-based healthcare. The ideal fit for remote care isn’t defined by size, specialty, or location, it’s defined by vision. The best-performing clinics are those that see beyond a single program and build an ecosystem of continuous care.

And with Lara Health, every practice (from a solo provider to a multi-site specialty group) can deliver that level of care effortlessly. Whether you manage your programs in-house or rely entirely on Lara Health’s Virtual Care Team, you get the same promise: compliant, scalable, and patient-centered care that pays for itself.

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Chronic Care Management isn’t just a billing program: it’s a bridge between good medicine and sustainable medicine.

The practices that thrive with CCM share one defining trait: they build strong, ongoing relationships with their patients. They know their names, their stories, their medications, and their struggles. They pick up the phone when a patient doesn’t show up. They follow up after a hospitalization, even when it’s not reimbursed, because it’s the right thing to do.

CCM rewards that kind of care. It gives structure, technology, and financial reinforcement to the compassion that already drives successful practices. It turns what was once invisible labor (the hours spent coordinating, calling, and caring) into measurable impact and recurring revenue. Chronic Care Management isn’t just a billing program: it’s a bridge between good medicine and sustainable medicine.

The best-suited practices for CCM

Clinics that already maintain consistent contact with their patients, especially those with large Medicare populations or high chronic-disease prevalence, see immediate benefits. CCM strengthens their existing workflows, builds predictable revenue, and supports staff retention by eliminating burnout from constant reactive care

For these clinics, CCM isn’t a leap — it’s an evolution.

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But what about practices without strong patient relationships?

If your practice doesn’t have deep, ongoing patient relationships today, ask yourself: Can you really afford to leave things that way?
In a world where value-based care, quality reporting, and patient satisfaction directly impact your revenue and reputation, disengaged patients aren’t just a clinical challenge, they’re a business risk. CCM offers a way to change that trajectory. By establishing a structured cadence of monthly communication, it:

• Rebuilds patient loyalty through consistent outreach and education.
• Reduces churn by keeping patients connected to your practice between visits.
• Improves clinical visibility, ensuring you’re aware of issues before they escalate.
• Positions your practice for long-term success in value-based care and population health contracts.
  

CCM doesn’t just help you stay connected, it helps you stay relevant. It turns once-fragmented relationships into enduring partnerships that patients value and rely on. Administrative chaos gives way to structure. Outreach becomes consistent, not crisis-driven. Providers regain time. Patients stay healthier.

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Why now is the time

Healthcare is changing fast. Reimbursement models are shifting toward outcomes, patient engagement, and continuity, exactly what CCM was built to support. Every month that care between visits goes unstructured is a missed opportunity to improve patient health, operational stability, and financial sustainability.

CCM gives you control. It strengthens relationships, stabilizes revenue, and lays the foundation for future growth. The only real question is: if your team is already doing the work (e.g. following up, coordinating, caring) why not get paid for it and make it sustainable?

Lara Health makes that transformation simple. It’s the only platform built to manage the entire alphabet soup of remote care programs, CCM, RPM, RTM, TCM, PCM, and APCM, in one seamless system.

With Lara Health, your practice can:

• Launch and scale-up CCM in weeks, not months, with training and support from industry experts.
• Automate compliance, documentation, and billing across all care programs.
• Use Lara Health’s Virtual Care Team to manage patients directly if staffing is limited.
• Gain visibility into performance and revenue through intuitive dashboards.
• Future-proof your operations as CMS expands value-based reimbursement.

The best practices for CCM are those that already care deeply about their patients, and the smartest ones are using CCM to make that care sustainable.

And for practices still struggling to stay connected, CCM isn’t just a billing opportunity, it’s the blueprint for rebuilding relationships, reclaiming efficiency, and restoring financial confidence. With Lara Health, every clinic can make that leap, from overworked to organized, from reactive to proactive, and from doing good work to being fairly rewarded for it. Book a demo with Lara Health to see how your practice can strengthen patient relationships, streamline operations, and unlock the financial future you deserve.

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Sources

CMS Medicare Learning Network (MLN) - Chronic Care Management Services (2025).

CMS MLN - Transitional Care Management Services

CMS MLN - Medicare Wellness Visits

CMS MLN Fact Sheet - Behavioral Health Integration (BHI) and Psychiatric Collaborative Care (CoCM).

CMS MLN Booklet - Remote Patient Monitoring and Remote Therapeutic Monitoring (RPM & RTM).

CMS - CY2025 Medicare Physician Fee Schedule Final Rule Fact Sheet.

AAFP. CCM FAQ and APCM Billing Codes.

HRSA. Rural Health Clinic Program Manual.

Peikes, D. et al. (2022). Health Affairs.

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FAQ

What is Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a Medicare-reimbursed program that pays providers for coordinating care between office visits for patients with two or more chronic conditions expected to last at least 12 months. CCM compensates practices for time spent on non-face-to-face work such as medication management, patient follow-ups, care-plan updates, and coordination with specialists.

Which types of practices benefit most from CCM?

CCM is a strong fit for primary care, internal medicine, and geriatric practices that manage large panels of chronically ill patients. Specialty practices such as cardiology, endocrinology, pulmonology, nephrology, rheumatology, and neurology can also benefit, especially when coordinating care for patients who need ongoing monitoring or multiple medications.

Can specialty practices bill for CCM too?

Yes. Specialists frequently provide CCM-eligible services, such as reviewing test results, adjusting medications, or coordinating with other providers. They can bill CCM codes just like primary care, often pairing it with Remote Patient Monitoring (RPM) to track physiologic data (e.g., blood pressure or glucose) and improve patient outcomes.

What if my practice doesn’t have long-term patient relationships?

If your practice doesn’t maintain ongoing relationships today, CCM can help build those relationships. Regular monthly communication creates patient loyalty, improves adherence, and boosts satisfaction. In today’s healthcare environment, can you afford not to have strong patient relationships? For practices focused on short-term or procedural care, alternative programs like Remote Therapeutic Monitoring (RTM) or Transitional Care Management (TCM) may be a better initial fit.

What if my clinic doesn’t have enough staff to manage CCM?

Lack of staff is not a barrier. Lara Health provides full flexibility:

• Practices with existing teams can use Lara Health’s platform to automate tracking, documentation, and billing.
• Clinics short on resources can fully outsource to Lara Health’s US-based Virtual Care Team, composed of licensed nurses, MAs, and care coordinators who operate under your supervision and workflows.
• This means you can start your CCM program without adding new hires.

Can CCM be billed alongside other remote-care programs?

Yes, but time can’t be double-counted. CCM may be billed in the same month as RPM (Remote Patient Monitoring), RTM (Remote Therapeutic Monitoring), or TCM (Transitional Care Management) as long as each program’s requirements are independently met and documented. Lara Health’s system prevents time overlap automatically to ensure compliance.

What are good alternatives to CCM for certain practice types?

• RTM (Remote Therapeutic Monitoring), ideal for physical therapy, orthopedics, and post-operative care.
• TCM (Transitional Care Management), best for clinics providing post-discharge follow-up within 30 days.
• BHI or CoCM (Behavioral Health Integration / Collaborative Care Model) - perfect for psychiatry and behavioral health.
• PCM (Principal Care Management), for practices managing patients with a single serious chronic condition.
• APCM (Advanced Primary Care Management), a broader model covering preventive and chronic care under one code set.

Why is Lara Health the best platform for CCM and remote care programs?

Because Lara Health covers the entire alphabet soup of remote care services (including CCM, RPM, RTM, TCM, PCM, and APCM) all in one place.
With Lara Health, practices can:

• Automate eligibility screening, patient enrollment, time tracking, and billing.
• Use built-in compliance and consent workflows to stay audit-ready.
• Launch new programs (e.g., adding RPM or RTM) without additional systems.
• Scale from fully in-house to fully outsourced, depending on staffing.
  

This unified model helps practices strengthen patient relationships, improve care quality, and maximize recurring revenue, all while staying compliant.

How long does it take to launch a CCM program with Lara Health?

Most clinics are live within 30–60 days. Lara Health provides:

• Implementation and training for your staff.
• Templates for care plans and documentation.
• Virtual care team support to ensure no delays.
• Real-time dashboards to monitor progress and revenue.

How do I know if my practice is ready for CCM?

If your team already manages patients with chronic conditions, coordinates between specialists, or spends time on follow-up calls and medication checks, you’re already doing the work CCM reimburses. The only thing missing is the structure and billing mechanism, which Lara Health provides.  If your practice cares deeply about its patients, CCM makes it sustainable. And if your patient relationships need strengthening, CCM helps you rebuild them, while paying you to do it.