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Services

Chronic Care Management (CCM)

Ongoing, between-visit care for patients living with two or more chronic conditions. We run the program and the billing so it becomes steady monthly revenue for your practice.

A chronic care plan on a clinic monitor showing patient conditions, care goals and monthly care time
What is CCM

Better care between visits, without adding to your staff’s workload

Medicare pays practices for the non-face-to-face care that chronic patients need every month. Most practices leave this revenue unbilled because the coordination and documentation take too much time. That is the part we handle.

  • ✓ Patients with 2+ chronic conditions expected to last 12 months or more
  • ✓ A comprehensive, patient-centered care plan for every enrolled patient
  • ✓ Monthly check-ins and care coordination, logged minute by minute
  • ✓ Claims submitted and followed up by our RCM team
2+
Chronic conditions per eligible patient
20 min
Monthly time threshold (CPT 99490)
12+ mo
Expected duration of conditions
Monthly
Recurring, billable service
What We Handle

End-to-end CCM program support

From finding eligible patients to getting paid. Every step of the monthly CCM cycle is covered.

A laptop showing referrals, follow-ups and a monthly care time log
01

Patient Identification & Enrollment

We review your patient panel for Medicare patients who qualify, then handle outreach and record consent before services begin.

A printed chronic care plan on a clipboard next to a stethoscope
02

Comprehensive Care Plans

Problem lists, measurable goals, medications and interventions, documented and kept current for every enrolled patient.

A care calendar on a tablet beside a phone showing a monthly care-team call
03

Monthly Check-ins

Scheduled check-ins with every patient to review symptoms, medications and upcoming needs.

04

Care Coordination

Follow-up on referrals, labs, refills and transitions of care, so nothing falls through the cracks.

05

Time Tracking & Documentation

Every minute is logged against the monthly time thresholds, so each claim is supported if it is ever audited.

06

CCM Billing & Claims

The right code every month, clean claim submission, and denial follow-up through our RCM team.

How It Works

A simple monthly cycle

01

Identify & enroll

We find eligible patients in your panel, explain the program and record their consent.

02

Plan & coordinate

Care plans are built and kept current. Check-ins and follow-ups happen every month.

03

Document & bill

Time is logged and the correct CCM codes are billed, then tracked until they are paid.

CCM codes we bill

Ready to launch CCM in your practice?

Book a free consultation and we will walk you through how CCM would work for your patients and your billing.

Care