What is CCM?
On a rainy Tuesday morning in a small-town clinic, Dr. Lawson reviews the chart of Mrs. Ramirez, a 72-year-old patient with type 2 diabetes, hypertension, and early-stage chronic kidney disease. She’s been seen in the office several times this year for follow-ups, but between visits, her health challenges don’t pause. Medication adjustments, lab orders, diet changes — each piece requires careful coordination. Without structured support, Mrs. Ramirez risks falling through the cracks, leading to avoidable ER visits or hospitalizations.
This is precisely where Chronic Care Management (CCM) comes in.
Defining CCM
Chronic Care Management (CCM) is a set of services, established by the Centers for Medicare & Medicaid Services (CMS), to support patients with multiple chronic conditions. At its core, CCM is about structured, proactive care between regular office visits. Rather than waiting for patients to present with acute problems, CCM enables providers to manage and coordinate care over the course of a month — improving outcomes and reducing costs.
CMS defines CCM as “non-face-to-face services provided to patients who have two or more chronic conditions expected to last at least 12 months (or until the patient’s death), that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.” These services are typically billed under CPT code 99490 and related codes for more complex cases.
Why CCM Matters for Providers and Patients
For providers, CCM offers a structured way to close care gaps, maintain patient engagement, and improve population health metrics — all while receiving reimbursement for the time and resources spent outside traditional visits.
For patients, CCM means ongoing attention to their health status, coordinated communication between specialists, and timely interventions before small issues escalate.
Example: Preventing Hospitalizations
Imagine a patient like Mr. Whitman, who has congestive heart failure and COPD. Through CCM, his nurse care coordinator checks in monthly, ensures medication adherence, monitors symptoms, and arranges follow-up tests before deterioration occurs. This proactive engagement can prevent a costly hospitalization, maintain his independence, and improve his quality of life.
Key Components of CCM
A compliant CCM program involves a comprehensive care plan developed with the patient, updated as needed, and accessible to the care team; at least 20 minutes of clinical staff time each month under the direction of a physician or other qualified healthcare professional; 24/7 access for patients to urgent care management and their care plan; continuity of care with a designated team member; and meticulous documentation to support billing compliance.
The Financial and Clinical ROI of CCM
CCM is reimbursable with base reimbursement for CPT 99490 averaging around $64 per patient per month (national, non-facility, CY2025). For a primary care practice with 200 eligible patients enrolled, that translates to approximately $153,600 annually — before considering additional codes like CPT 99487, which covers complex CCM requiring at least 60 minutes per month, or CPT 99491 for physician/NP-provided CCM.
Clinically, CCM programs have been associated with reductions in hospitalizations, lower total cost of care, and improved patient satisfaction. CMS data indicates that practices effectively implementing CCM see measurable improvements in preventive service uptake and chronic disease management metrics.
Implementing CCM in Your Practice
A successful CCM program requires identifying eligible patients; obtaining and documenting informed patient consent; creating and maintaining a patient-specific care plan with measurable goals; integrating workflows to assign roles to care team members; and using technology that simplifies compliance. Lara Health’s platform automates eligibility checks, streamlines documentation, tracks time automatically, and integrates with EHR systems — enabling efficient delivery without disrupting provider schedules.
Common Pitfalls to Avoid
Some practices struggle with CCM because they underestimate the operational complexity. Common issues include failure to document required elements like consent or care plan details, inconsistent time tracking that leads to claim denials, insufficient patient engagement due to unclear expectations, and assigning CCM duties to already overextended staff without providing process adjustments or tools.
Compliance and Audit Readiness
CCM services are subject to CMS audit. To be audit-ready, practices must maintain detailed documentation of all patient interactions, ensure care plans are kept current and shared with patients either electronically or in print, track exact minutes of clinical staff time each month, keep signed patient consent on file, and confirm that services billed are not duplicated by another provider in the same month.
Why Lara Health Makes CCM Effortless
Lara Health’s platform automates eligibility verification, generates compliant care plan templates, tracks time, and integrates with existing systems. This allows care teams to focus on patient health rather than administrative burden, ensuring CCM delivery is consistent, compliant, and impactful.
Every CCM interaction is a chance to keep patients stable, independent, and engaged — and to reward the provider’s commitment to continuous care. Learn more about CCM with Lara Health and see how automation, smart prompts, and seamless integration can transform your chronic care program.
FAQs
Who is eligible for CCM?
Patients with two or more chronic conditions expected to last at least 12 months, that place them at significant risk of death, acute exacerbation, or functional decline.
Does CCM require in-person visits?
No. CCM is primarily non-face-to-face care provided between office visits.
How much time is required per month?
At least 20 minutes of clinical staff time under the supervision of a qualified healthcare provider.
Can multiple providers bill CCM for the same patient?
No. Only one provider can bill CCM for a patient in a given month.
Is patient consent required?
Yes. Consent must be documented before initiating CCM services.
Sources
CMS Chronic Care Management
AMA CPT Code 99490 Descriptor
CMS Medicare Learning Network: Chronic Care Management Services
