{"id":20667,"date":"2019-01-07T09:00:14","date_gmt":"2019-01-07T14:00:14","guid":{"rendered":"http:\/\/www.carecloud.com\/continuum\/?p=20667"},"modified":"2025-10-21T17:29:47","modified_gmt":"2025-10-21T17:29:47","slug":"chronic-care-management","status":"publish","type":"post","link":"https:\/\/carecloud.com\/continuum\/chronic-care-management\/","title":{"rendered":"What is Chronic Care Management?"},"content":{"rendered":"

The Ins & Outs of Chronic Care Management<\/span><\/h2>\n

By Meghan Franklin<\/span><\/i><\/p>\n

In 2015, Centers for Medicare and Medicaid Services (CMS) began paying separately under the Medicare physician fee schedule for chronic care management (CCM) provided to Medicare patients with two or more chronic conditions. <\/span><\/p>\n

According to <\/span>CMS<\/span><\/a>, approximately one in four adults have two or more chronic health conditions\u2014things like Alzheimer\u2019s disease, autism spectrum disorders, certain types of cancers, depression, osteoporosis, HIV\/AIDS and hypertension. <\/span><\/p>\n

CMS\u2019s decision to reimburse for CCM services reflects an industry-wide shift towards value-based care and the increasing value payers are assigning to proactive efforts to manage patients\u2019 health. <\/span><\/p>\n

So, what constitutes CCM? <\/span><\/h2>\n

CMS defines CCM as \u201ccare 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 place the patient at significant risk of death, acute exacerbation\/decompensation, or functional decline.\u201d <\/span><\/p>\n

CMS\u2019s CCM program allows for physicians, physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives to bill for at least 20 minutes or more of care coordination services per month. Only one practitioner can bill for CCM services per patient during any given month. <\/span><\/p>\n

What might a patient participating in a CCM encounter? <\/span><\/h2>\n

CMS makes the patient an active participant in CCM; an important tenet of care coordination. A patient receiving CCM services must explicitly consent \u2013 either verbally or in writing– to receiving such services. Consent must be documented in the medical record, and, per CMS, the patient must be informed about: \u201cthe availability of CCM services and applicable cost-sharing, that only one practitioner can furnish and be paid for CCM services during a calendar month, and the right to stop CCM services at any time.\u201d <\/span><\/p>\n

So, first and foremost, patients must understand what CCM entails and agree to participate. Once they\u2019ve elected to participate, the <\/span>American Academy of Family Physicians<\/span><\/a> says there are eight things that patients can expect while participating in CCM: <\/span><\/p>\n