PULSE 9/12/2025: Is Chronic Care Management Right for Your Practice?

Physicians caring for Medicare patients with multiple chronic conditions know the challenge: missed medications, poor follow-up, and avoidable hospitalizations. To address these gaps, the Centers for Medicare & Medicaid Services (CMS) established Chronic Care Management (CCM), a reimbursable program that extends your care team’s reach beyond office visits.

What CCM Provides

CCM is designed for Medicare beneficiaries with two or more chronic conditions expected to last at least 12 months (or until death) and place them at significant risk of decline. Eligible conditions include diabetes, hypertension, COPD, arthritis, depression, heart failure, and more.

Patients enrolled in CCM receive:

• A comprehensive care plan developed by you or your team.
• Monthly non-face-to-face care (minimum of 20 minutes).
• 24/7 access to clinical staff for urgent concerns.
• Medication and treatment plan reviews with proactive follow-up.

Enrollment begins during an Annual Wellness Visit, routine E/M service, or other face-to-face encounter, ensuring informed consent and continuity of care.

Why It Matters for Physicians

The clinical and operational benefits are significant:

• Improved outcomes: A 2021 American Journal of Managed Care study found CCM reduced hospitalizations by 15%.
• Preventive care: Early intervention reduces acute exacerbations and ED visits.
• Patient satisfaction: Seniors appreciate the ongoing connection to their care team.
• Revenue opportunity: Medicare reimburses for CCM time, making it a sustainable service line for practices.

How It Works in Your Workflow

Your practice can implement CCM through:

1. Care plan development integrated into your EHR.
2. Delegation to clinical staff under your supervision.
3. Monthly documentation of time and activities to support billing.
4. Leveraging technology partners (optional) for care coordination, monitoring, and compliance tracking.

📌 CCM At a Glance: Billing & Reimbursement

• CPT 99490 – 20 min non-face-to-face clinical staff time, per month
  Avg. reimbursement: ~$42 per patient/month
• CPT 99439 (add-on) – Each additional 20 min clinical staff time
  Avg. reimbursement: ~$38
• CPT 99491 – 30 min physician or qualified health professional time, per month
  Avg. reimbursement: ~$84
• CPT 99437 (add-on) – Each additional 30 min physician time
  Avg. reimbursement: ~$70

💡 Tip: Even a panel of 100 patients enrolled in CCM can generate meaningful recurring revenue while improving patient outcomes.

Outsourcing CCM: A Practical Option

For many physicians, the barriers to adopting CCM are the administrative workload, care coordination, patient outreach, documentation, and billing compliance, all of which demand significant staff time. One solution is to partner with a dedicated CCM company such as ChronicCare, which provides these services under your clinical supervision. ChronicCare’s pharmacist-led team specializes in medication management, remote patient monitoring, and patient engagement strategies that keep beneficiaries on track with their care plans. By outsourcing to ChronicCare, practices can scale enrollment, reduce staff burden, ensure CMS compliance, and generate consistent reimbursement while delivering better outcomes for their Medicare patients.

Benefits of outsourcing CCM include:

• Reduced administrative burden: frees your staff from routine calls, follow-ups, and paperwork.
• Scalability: allows your practice to enroll more patients without hiring additional staff.
• Assured compliance: partner companies specialize in meeting CMS documentation and billing requirements.
• Improved financial performance: physicians retain reimbursement revenue with minimal investment in new infrastructure.
• Enhanced patient satisfaction: patients experience continuous engagement from trained care coordinators, improving adherence and outcomes.

Is CCM Right for Your Practice?

For MSSNY physicians, CCM represents a win-win: enhanced patient care, reduced hospital utilization, and a new revenue stream aligned with value-based care goals. Whether implemented in-house or outsourced to a partner, CCM allows practices to extend care beyond the office and improve the lives of Medicare patients with chronic conditions.

Learn more about this MSSNY member benefit and start transforming your practice today.