Understanding Chronic Care Management (CCM)
Chronic Care Management (CCM) is a Medicare program designed to help patients with multiple chronic conditions better understand and manage their health. Through CCM, patients receive ongoing support from a care coordinator who assists them in setting health goals, scheduling appointments, refilling medications, and connecting with community resources. However, many practices are unfamiliar with CCM or unsure which conditions qualify patients for the program. Below, we’ll explore the chronic conditions that make patients eligible for CCM and how this program can empower patients to take control of their health.
What Conditions Qualify for CCM?
To qualify for CCM, patients must have two or more chronic conditions that are expected to last at least 12 months and place them at risk of worsening health or functional decline. While providers ultimately determine which patients are eligible, here’s a comprehensive list of common conditions that often qualify:
Cardiovascular and Blood Conditions
- Hypertension
- Ischemic heart disease
- Congestive heart failure
- Anemia
- Atrial fibrillation
- Hyperlipidemia
- Diabetes
- Coronary artery disease
- Peripheral vascular disease (PVD)
- Sickle-cell disease
Cancer and Oncology Conditions
- Breast cancer
- Lung cancer
- Prostate cancer
- Colorectal cancer
- Leukemias and lymphomas
Bone, Joint, and Muscle Conditions
- Osteoporosis
- Rheumatoid arthritis
- Osteoarthritis
Eye Conditions
- Cataracts
- Glaucoma
- Diabetic retinopathy
- Age-related macular degeneration
Urology and Nephrology Conditions
- Chronic kidney disease
- Benign prostatic hyperplasia
- Kidney cysts
Gastroenterological Conditions
- Irritable bowel syndrome (IBS)
- Crohn’s disease
- Ulcerative colitis
Ear, Nose, and Throat (ENT) Conditions
- Sleep apnea
- Tinnitus
- Vertigo
- Hearing loss
Mental Health and Neurological Conditions
- Alzheimer’s disease and dementia
- Anxiety disorders
- Depressive disorders
- Bipolar disorder
- Schizophrenia
- Migraines and chronic headaches
- Epilepsy
- Parkinson’s disease
- Traumatic brain injury
Respiratory Conditions
- Asthma
- Chronic obstructive pulmonary disease (COPD)
- Emphysema
- Cystic fibrosis
Substance Use Disorders
- Alcohol dependence
- Opioid dependence
- Nicotine dependence
- Other drug use disorders
Autoimmune Conditions
- HIV/AIDS
- Viral hepatitis
- Multiple sclerosis
- Hypothyroidism
Other Disabling Conditions
- Spinal cord injury
- Muscular dystrophy
- Fibromyalgia
- Chronic pain
- Obesity
- Developmental and intellectual disabilities
- Liver disease and cirrhosis
- Blindness and visual impairment
- Meniere’s disease
How CCM Works
When a practice partners with Compass CCM, our software helps identify eligible patients based on CMS guidelines. Providers then review the list and determine which patients would benefit most from the program. Once a patient is identified as eligible, they are informed about CCM and given the option to enroll.
What Happens After Enrollment?
- Monthly Care Coordination: Patients receive at least 20 minutes of non-face-to-face care coordination each month. This includes follow-ups on care goals, medication management, and assistance with scheduling appointments.
- Comprehensive Care Plan: A personalized care plan is created for each patient, which they can access at any time. This plan outlines their health goals, treatment strategies, and resources available to them.
- 24/7 Access to Care: While Compass CCM does not provide monitoring services, our software ensures that practices can efficiently manage patient interactions and documentation, enabling providers to offer around-the-clock support if needed.
- Resource Connection: Care coordinators help patients access community resources, such as food banks, transportation services, and emotional support programs.
The Role of Compass CCM Software
Compass CCM provides the tools and software needed to streamline Chronic Care Management for your practice. Our platform helps:
- Identify Eligible Patients: Automatically generate a list of patients who meet CMS criteria for CCM.
- Simplify Documentation: Easily track patient interactions, care plans, and progress within the software.
- Ensure Compliance: Stay up-to-date with CMS billing requirements, including CPT codes like 99490 (for 20 minutes of care per month) and 99439 (for additional 20-minute increments).
- Enhance Patient Engagement: Facilitate regular communication between providers and patients, ensuring continuity of care.
Why CCM Matters
Chronic Care Management is more than just a program—it’s a way to improve the quality of life for patients with chronic conditions. By participating in CCM, practices can:
- Improve Health Outcomes: Regular check-ins and personalized care plans help patients better manage their conditions.
- Increase Patient Satisfaction: Patients feel supported and empowered to take an active role in their health.
- Boost Practice Revenue: CCM services are reimbursable under Medicare, providing an additional revenue stream for your practice.
Key Takeaways
Chronic Care Management is a valuable program for Medicare patients with multiple chronic conditions. By leveraging Compass CCM’s software, practices can efficiently identify eligible patients, streamline care coordination, and ensure compliance with CMS guidelines. While Compass CCM does not provide monitoring services, our platform empowers providers to deliver high-quality, patient-centered care that improves outcomes and enhances practice efficiency. If you’re ready to take your chronic care management to the next level, Compass CCM is here to help.
