Chronic Care Management for Providers Scalable CCM Platform
Clinii’s Chronic Care Management (CCM) platform helps healthcare teams support patients with multiple
chronic conditions — while streamlining workflows and boosting revenue. From patient eligibility to care
planning, documentation, and billing, Clinii’s EMR-integrated platform makes it easy to scale reimbursable care.
What is Chronic Care Management?
Chronic Care Management (CCM) is care coordination that occurs outside of regular office visits for patients with two or more chronic conditions expected to last at least 12 months (or until death), and that place the patient at significant risk of death, acute exacerbation or decompositions, or functional decline.
1. Enhance Patient Outcomes
CCM facilitates proactive and continuous care, leading to improved patient health outcomes. By providing regular check-ins, personalized care plans, and coordinated services, patients experience better chronic condition management and a higher quality of life. This approach not only benefits patients but also strengthens the patient-provider relationship.
2. Reduce Hospitalizations and Emergency Visits
CCM helps to decrease hospital admissions and emergency room visits. By closely monitoring patients and addressing health issues promptly, providers can prevent complications that often lead to acute health issues. This not only improves patient well-being but also reduces the strain on healthcare facilities.
3. Generate Additional Revenue Streams
CCM services are eligible for reimbursement under Medicare, giving healthcare providers the opportunity to generate additional revenue. For instance, CCM for a panel of patients can result in significant monthly income, enhancing the financial sustainability of a practice.
4. Streamline Care Coordination
CCM promotes comprehensive care coordination among various healthcare providers, ensuring that patients receive consistent and well-organized care. This collaborative approach reduces the number of redundant tests, procedures, and medication errors, and ensures that all aspects of a patient's health are addressed cohesively.
5. Improve Operational Efficiency With CCM Software
Utilizing CCM software streamlines administrative tasks, such as scheduling, documentation, and billing. Clinii’s platform integrates with many EMRs, allowing for seamless information sharing and a reduction in errors. By automating routine tasks, providers can focus more on direct patient care.
6. Facilitate Patient Engagement and Self-Management
Clinii’s CCM software includes patient portals and communication tools that empower patients to take an active role in managing their health. Features such as medication reminders, appointment scheduling, and direct messaging with care teams increase patient engagement, ultimately leading to stricter adherence to treatment plans and improved health outcomes.
CPT Codes
Non-Complex Provider
CPT 99491
Chronic care management by a physician or other qualified healthcare professional for 30 minutes.
CPT 99437
Additional 30 minutes of chronic care management services by clinical staff.
Complex Clinical Staff
CPT 99487
Complex chronic care management services, first 60 minutes, performed by clinical staff.
CPT 99489
Additional 30 minutes of complex chronic care management services by clinical staff.
Non-Complex Clinical Staff
CPT 99490
At least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
CPT 99439
Each additional 20 minutes of chronic care management services provided by clinical staff.
Frequently Asked Questions About Chronic Care Management
1. What is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is a care coordination program for patients with two or more chronic conditions that are expected to last at least 12 months and place them at significant risk of health decline. It includes non-face-to-face services like care planning, medication management, and health coaching — all documented and billable under specific CPT codes.
2. Who Qualifies for CCM?
Patients qualify for CCM if they have at least two chronic conditions that are expected to last a year or more (or until death) and significantly increase their risk of hospitalization, functional decline, or serious health events.
3. Which CPT Codes Are Used for CCM Billing?
The most commonly used CPT codes for CCM include:
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99490: 20+ minutes of clinical staff time per month
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99439: Each additional 20 minutes
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99491: 30+ minutes of time by a physician or qualified health professional
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99437: Add-on code for additional time under 99491
4. How Does Clinii Support CCM Workflows?
Clinii’s platform automates every step of the CCM process — from patient eligibility checks and task tracking to care plan documentation and billing code generation. It integrates directly with your EMR and supports scalable, compliant care coordination.
5. Can Patients Be Enrolled in CCM and Other Care Programs at the Same Time?
Yes. Patients can be enrolled in CCM alongside other reimbursable programs like Principal Care Management (PCM) or Annual Wellness Visits (AWV), as long as time and documentation requirements for each program are met.
6. How Does CCM Impact CMS Reimbursement for Providers?
CCM services are reimbursed by Medicare under specific CPT codes, allowing providers to earn additional revenue for delivering non face-to-face care coordination. By enrolling eligible patients and documenting care activities properly, practices can enhance revenue streams while improving patient outcomes. Accurate time tracking and compliance with CMS guidelines are key to maximizing reimbursements.
7. What is the Difference Between CCM and Complex CCM?
There are two different types of CCM: Standard CCM and complex CCM. Standard CCM can be distinguished from complex CCM by the respective CPT code. Complex CCM uses codes 99487 and 99489. Complex CCM patients’ care teams must have a significant establishment or revision of the care plan and typically communicate more with the care team staff in a calendar month.
8. Which Practitioners Are Eligible to Bill Medicare for CCM?
Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, certified nurse-midwives, or the provider to which such individual has reassigned their billing rights are eligible to bill Medicare for CCM. Other non-physician practitioners and limited-license practitioners (e.g., clinical psychologists or social workers) and providers not eligible for reimbursement under the Medicare Physician Fee Schedule (e.g., pharmacists) cannot bill for CCM.
9. Can Patients Be Enrolled in Multiple Care Programs at the Same Time?
Yes. Patients can be enrolled in more than one care program — such as Chronic Care Management (CCM), Principal Care Management (PCM), and Annual Wellness Visits (AWV) — as long as the required documentation and time thresholds are met for each service. Clinii is built to support this layered care delivery model without added operational complexity.