Chronic Care Management, a growing piece of the digital health landscape – #HITsm Chat Topic

We’re excited to share the topic and questions for this week’s #HITsm chat happening Friday, 3/6 at Noon ET (9 AM PT). This week’s chat will be hosted by Joy Rios (@askjoyrios) and Robin Roberts (@RRobertseHealth) from Chirpy Bird (@chirpybirdhit) on the topic of “Chronic Care Management, a growing piece of the digital health landscape”.

For many patients, healthcare doesn’t end at the hospital or the doctor’s office. That’s why the Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management (CCM) as a key component of primary care, reimbursing practices for supporting patients outside the office.

There’s no need to debate – chronic health conditions are a costly burden to the healthcare industry and its overall spend. In order to better support patients with chronic conditions, digital health has come to the rescue and continues to expand year-over-year. At the forefront of service support we find chronic condition management (CCM).


Chronic care management is care coordination services done outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that places the patient at significant risk of death, acute exacerbation, or functional decline. These CCM services typically involve non-face-to-face encounters and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month. CMS recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.


CCM offers an opportunity to increase clinical revenue while also improving the ability for patients who are Medicare Fee-For-Service (FFS) beneficiaries and have multiple chronic conditions to self-manage their conditions as well as to improve both their health outcomes and satisfaction. Improving care delivery and outcomes for persons with chronic illnesses is a high priority for CMS and other private insurance payers.

There are studies that demonstrate that the initial health appraisal that may be needed, such as a Medicare Annual Wellness visit, development of personalized care plans, medication management, and a call line to a trained health professional improve outcomes and reduce the adverse clinical events.  The reduction of exacerbated and emergent patient needs contributes to an overall reduction in healthcare costs for payers and patients. The communication, access, and care provided to patients also poses ample opportunity to improve overall patient satisfaction when well executed.


Anytime CMS roles out new codes or expands programs, there is hesitation by practice’s and health systems to utilize and bill them. MGMA officials have commented that, “In the past, administrative requirements associated with other newly recognized services, such as chronic care management (CCM) codes, have prevented group practices from being eligible to receive reimbursement for care management efforts.” Of course, no one wants to spend time, effort, and resources to bill something only to have the claim denied, or worse frustrate patients along the way.

Practices have the clinical know-how to conduct CCM and are already doing much of the work already. However, knowing the “rules of the road” for any new codes are critical to successful deployment and implementation. Some of the most common hurdles include:         

Practice readiness to expand for CCM

Does the office have the means to maintain an electronic care plan that can be shared timely with other physicians or providers?

Does the office offer expanded access for patient to access their information and its physicians or other providers 24/7?

Is there a care manager in place?

Is there a designated staff member responsible for enrolling patients?

Is there a designated staff member to perform CCM duties and document what actions are being taken?

Patient eligibility

CCM is intended for Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that places the patient at significant risk of death, acute exacerbation, or functional decline.

What patients with two or more chronic conditions will benefit or are most critical?

Patient consent

Patients have to agree and understand their co-pay or other cost-sharing obligations.

 Initiating visit

For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit or Initial Preventive Physical Exam, or other face-to-face visit with the billing practitioner).  

Documentation and timekeeping

Physicians and practices must have a mechanism to ensure they parse and track their CCM time to meet the required minimum of 20 minutes.

Billing limitations & details

The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. Ex. Do not report 99491 in the same calendar month as 99487, 99489, 99490.


CCM service is extensive, including structured recording of patient information, maintaining a comprehensive electronic care plan, managing transitions of care, and coordinating and sharing patient health information timely, both within and outside of the practice.

CCM offers practitioners a bridge over the chasm between fee-for-service and value-based reimbursement. By developing and implementing a CCM program, a practitioner will grow skill sets and internal processes critical to population health management, all the while receiving fee-for-service payment to support those activities.

As a consultancy with its eyes toward value-based care, CBI is invested in supporting clinicians bridge this gap through CCM. We’ll be delivering a special two-hour workshop (one hour each day) on March 25 and 26 through 4Medapproved on how to implement a CCM program in your practice. Also, if you’re interested in having a CCM program in your practice to support your patients, please contact us at


Join us for this week’s #HITsm chat where we’ll discuss the chronic care management.

Topics for this week’s #HITsm Chat:

T1: 35 million individuals suffer from multiple chronic conditions, but less than 10% receive chronic care management (CCM) services. What do you think the biggest hurdles are for providers? #HITsm

T2: What about patients? Are they up to speed on using digital health for services beyond telehealth, such as chronic care management (CCM)? #HITsm

T3: Can CCM truly help cross the chasm from fee-for-service to value-based reimbursement? How so? #HITsm

T4: CCM requires care coordination with home- and community-based clinical service providers to meet the patient’s psychosocial needs and functional deficits. How might this impact the way we address SDOH for this population? #HITsm

T5: Is the expansion of digital health codes, like CCM, truly helping patient care? Do you have any success stories or lessons learned from the field to share? #HITsm

Bonus: Digital health will continue to expand. What is missing from CCM services? What else could we be doing to support patients with two or more chronic conditions? #HITsm

Upcoming #HITsm Chat Schedule
3/13 – No Chat, but Enjoy #HIMSS20

3/20 – COVID-19
Hosted by the CHIME Liaisons

3/27 – #UnblockHealth
Hosted by Grace Cordovano (@GraceCordovano)

4/3 – TBD
Hosted by TBD

4/10 – Emerging Strategies for Measuring and Managing Provider Burnout
Hosted by Jeffrey Becker (@BeckerJMB)

We look forward to learning from the #HITsm community! As always, let us know if you’d like to host a future #HITsm chat or if you know someone you think we should invite to host.

If you’re searching for the latest #HITsm chat, you can always find the latest #HITsm chat and schedule of chats here.

About the author

John Lynn

John Lynn

John Lynn is the Founder of, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.