Healthcare in America faces a critical challenge: chronic diseases cause seven out of ten deaths and consume roughly 86 % of all healthcare spending. Yet our current system wasn’t built to handle ongoing care—it focuses on brief, episodic visits rather than continuous support between visits. That’s why the structured approach of Chronic Care Management (CCM) matters. Rather than simply seeing patients when they show up, CCM ensures ongoing support—care teams check in regularly, help with medication and condition management, monitor changes, and catch problems before they become emergencies.

The evidence is clear: fewer hospitalizations, better outcomes for patients, and practices that become true partners in health, not just transaction points. (If you’d like to dig deeper into the foundations of CCM—eligibility, services, billing, benefits, and more—see our comprehensive guide: “Chronic Care Management: Complete Guide”.)

However, launching a CCM program isn’t plug-and-play. It demands thoughtful planning, the right team, effective systems, and reliable workflows. In this article, we’ll walk you through a five-step checklist to build a CCM program that not only works for your practice but makes a real difference for your patients.

Understanding Chronic Care Management Basics

How CCM Reimbursement Works

Medicare began paying for CCM services in 2015. The main billing codes—99490, 99491, and 99439—reimburse practices for care coordination work done outside of regular office visits.
Here’s what you need to know:

• The basic code (99490) requires 20 minutes of non–face-to-face care coordination per patient each month (provided by clinical staff under the direction of a physician or qualified health professional).
• You can bill for extended time using the add-on code (99439), which is applicable for each additional 20 minutes of care coordination in a calendar month, and national average reimbursement is about $45.93 for that add-on (though actual reimbursement varies by geography/payer).
• If the physician or other qualified health professional personally provides at least 30 minutes of CCM in a month, you bill code 99491 (with add-on 99437 for additional 30-minute increments).
• Many private insurance companies now offer similar reimbursement models (though time thresholds, codes, and rates differ by payer).

The payment structure encourages ongoing patient relationships rather than one-time visits. This creates a sustainable way for practices to provide better care while maintaining financial stability.

Which Patients Qualify

Patients must meet these requirements before beginning the CCM program:

• Two or more chronic conditions expected to last at least 12 months or until the death of the patient, and these conditions must put the patient at risk for serious health problems or functional decline.
• If the patient has not had a face-to-face visit (such as an Evaluation & Management visit, an Annual Wellness Visit, or an Initial Preventive Physical Exam) with the billing practitioner within the past 12 months, that visit must be completed before starting the CCM program.

Common qualifying conditions include:

• Diabetes
• Heart failure
• High blood pressure
• COPD (chronic lung disease)
• Arthritis
• Depression
• Kidney disease
• Asthma

After those eligibility criteria are met (and the initiating visit is done), informed consent must be obtained from the patient — clearly explaining the program, setting expectations, and building trust from the start.

Step 1: Build Your Foundation

Set Up Your Technology

Your electronic health record (EHR) system needs to support CCM activities. Look for these features:

Essential EHR capabilities:

• Templates for care plans and monthly documentation
• Time tracking for billable activities
• Communication logs that capture all patient interactions
• Automated reports showing which patients need outreach

CCM-Specific Modules:

Many EHR vendors offer CCM-specific modules. These often include compliance checks and simplified documentation. Evaluate whether your current system meets your needs or if you should add specialized software.

Integration Matters:

Your system should pull in information from labs, hospitals, and specialists automatically. This saves time and ensures your team sees the complete picture of each patient’s health.

Billing Overlap Note: Ensure your documentation and workflows clearly delineate time spent on CCM from services billed under Principal Care Management (PCM) or Remote Patient Monitoring (RPM), as these services often target the same patients but are billed separately. Avoid double-billing for the same time spent on coordination.

Build Your Care Team

Successful CCM programs use team-based care. Each member plays a specific role:

• Registered Nurses typically serve as primary care coordinators. They conduct assessments, review medications, and monitor for concerning symptoms. Their clinical training helps them recognize when patients need urgent attention.
• Medical Assistants or Health Coaches can handle specific tasks under supervision, like scheduling follow-ups or providing basic education.
• Pharmacists bring valuable expertise for patients on multiple medications. They can identify drug interactions and recommend safer alternatives.
• Physicians oversee the program, review care plans, and handle complex clinical decisions. While they delegate routine coordination, they remain involved in important decisions.

Staffing Capacity: How many patients can one coordinator manage? Most handle 150-300 patients depending on how sick the patients are and how intensive the program is. Too few staff leads to burnout. Too many creates financial problems.

Choose Communication Tools

Patients need easy ways to reach your team. Offer multiple options:

• Phone calls remain the foundation—essential for detailed conversations
• Secure messaging through patient portals lets patients ask questions anytime
• Video visits help when patients can’t travel to the office
• Text reminders work well for appointment and medication reminders

Different patients prefer different methods. Older adults may prefer phone calls, while working adults appreciate messaging. Offering choices increases engagement.

Important: Document every interaction in your EHR, regardless of how patients contact you. This proves you provided the services you’re billing for.  

Step 2: Create Effective Care Plans

Use Evidence-Based Protocols

Care plans should reflect the latest clinical guidelines. Develop standard protocols for common conditions that your team can customize for each patient.

Example: Diabetes care plan elements

• Blood sugar monitoring schedule
• Eye exam reminders
• Foot check protocols
• Medication review schedule
• Nutrition counseling topics
• Exercise recommendations

Update your protocols regularly as medical evidence evolves. Include input from specialists—endocrinologists for diabetes plans, cardiologists for heart failure protocols, etc.

Build clinical decision support into your templates. This guides care coordinators through systematic assessments and prompts them to consider important interventions.

Personalize for Each Patient

Standard protocols need tailoring. Every patient has unique circumstances, preferences, and barriers to care.

Consider these factors:

• Health literacy: Can they understand complex instructions?
• Financial resources: Can they afford medications and healthy food?
• Support system: Do they have family help or live alone?
• Cultural beliefs: Do they have preferences about treatments?
• Mental health: Are depression or anxiety affecting their self-care?

Involve patients in creating their care plans. Ask what matters most to them. Someone who wants to attend their grandchild’s wedding has a powerful motivation—connect medical goals to these personal aspirations.

Set Clear, Achievable Goals

Vague goals don’t work. “Get healthier” means nothing concrete. Instead, use the SMART framework:

• Specific: Target exact outcomes (not “lower blood sugar” but “reduce A1c from 9.2% to 8.0%”)
• Measurable: Include numbers you can track
• Achievable: Set realistic targets based on the patient’s starting point
• Relevant: Connect to what matters to the patient
• Time-bound: Set a specific deadline (usually 3-6 months)

Break big goals into smaller milestones. Instead of “lose 30 pounds,” start with “lose 2 pounds this month.” Small wins build confidence and momentum.

Step 3: Identify and Enroll the Right Patients

Find High-Risk Patients

Use your EHR data to identify patients who need CCM most:

• Recent hospitalizations or ER visits
• Multiple chronic conditions
• Poor disease control (high A1c, uncontrolled blood pressure)
• Frequent office visits or calls
• Medication non-adherence

Run reports that flag patients meeting these criteria. Many practices start with their sickest patients—those most likely to benefit immediately.

Consider social factors too. A patient with diabetes and stable housing differs from someone with diabetes who’s homeless. Both have chronic conditions, but one faces much greater challenges and needs more intensive support.

Conduct Outreach Effectively

First impressions matter. Your enrollment approach sets the tone for the entire relationship.

Best practices for outreach:

1. Send an introductory letter explaining the program before calling
2. Use a warm, conversational tone during phone calls (not scripted and robotic)
3. Explain benefits clearly: “You’ll have a nurse you can call anytime with questions”
4. Be transparent about costs if there’s a copay
5. Answer questions patiently
6. Respect “no” but leave the door open for future enrollment

Some patients need time to think. Others decline until they experience a health crisis and realize they need more support. Follow up periodically with those who initially declined.

Address Cultural and Language Needs

Your patient population includes diverse backgrounds. Adapt your approach accordingly:

• Use professional interpreters for patients with limited English
• Recognize that some cultures emphasize family decision-making (include family members)
• Understand that health beliefs vary across cultures
• Accommodate patients without reliable phones or housing

Flexibility is key. For a homeless patient, coordinate with their case manager. For someone without a phone, schedule regular in-person check-ins.

Step 4: Provide Ongoing Monitoring and Support

Conduct Monthly Check-Ins

Medicare requires at least one contact per enrolled patient each month. These aren’t brief calls—they’re comprehensive assessments.

What to cover during monthly contacts:

• How they’re feeling since the last check-in
• New or worsening symptoms
• Medication adherence and side effects
• Whether they’re following their care plan
• Upcoming appointments with specialists
• Questions or concerns they have

Document everything thoroughly. Notes should show exactly what you discussed and how long it took. “Spoke with patient” isn’t enough. Write “25-minute call to assess diabetes management; reviewed blood sugar logs showing morning readings 180-240; discussed adjusting insulin dose with Dr. Smith; educated about carbohydrate counting; scheduled follow-up call in 2 weeks.”

Sicker patients need more frequent contact. Don’t limit yourself to the monthly minimum if someone needs weekly support.

Use Remote Monitoring Technology

Remote patient monitoring (RPM) devices send health data directly to your team:

• Blood pressure cuffs
• Weight scales
• Blood glucose meters
• Pulse oximeters

Patients take measurements at home, and the devices transmit results automatically. Your team sees the data in real-time and gets alerts when readings are concerning.

Benefits of remote monitoring:

• Catch problems early (before patients feel sick)
• Track trends over time
• Reduce the need for in-person visits
• Help patients stay engaged with their health

Provide clear instructions on device use. Many patients need hands-on training and ongoing troubleshooting support.

Know When to Escalate

Care coordinators handle routine issues, but they must recognize when to involve the physician immediately.

Situations requiring urgent physician notification:

• Chest pain or difficulty breathing
• Severe pain
• Blood pressure dangerously high or low
• Significant unexplained weight gain (suggests fluid retention)
• Confusion or mental status changes
• Patient expressing suicidal thoughts

Create clear escalation protocols so staff know exactly what to do. Regular training with case examples helps coordinators develop good clinical judgment.

Set up after-hours coverage too. Patients get sick at night and on weekends—they need access to guidance when your office is closed.

Step 5: Measure Results and Improve Continuously

Track Key Performance Indicators

You can’t improve what you don’t measure. Monitor both clinical and operational metrics.

Clinical outcomes to track:

• Disease control measures (A1c levels, blood pressure averages)
• Hospital admission rates
• ER visit frequency
• Medication adherence rates
• Patient satisfaction scores

Operational metrics to monitor:

• Percentage of enrolled patients receiving monthly contact
• Average time spent per patient per month
• Care plan completion rates
• Documentation quality scores
• Staff productivity and workload

Review these metrics monthly. Look for patterns—are certain care coordinators getting better results? Are specific patient groups struggling?

Ensure Financial Sustainability

Track program costs versus revenue carefully:

Revenue sources:

• CCM billing reimbursement
• Reduced hospital costs (if in value-based contracts)
• Quality bonus payments

Expenses to account for:

• Staff salaries and benefits
• Technology costs (software, devices)
• Training and education
• Administrative overhead

Calculate your break-even point. How many enrolled patients do you need to cover costs? Most practices need 200-300 enrolled patients for a sustainable program.

Prevent billing errors that cost you revenue. Common mistakes include incomplete documentation, billing for the same patient twice in one month, and failing to get proper consent.

Make Data-Driven Improvements

Use your metrics to guide changes. This is continuous quality improvement in action.

The improvement cycle:

1. Identify a problem: “Only 60% of diabetes patients are reaching target A1c”
2. Analyze the cause: Review charts to understand why (medication adherence? Diet? Follow-up gaps?)
3. Test a solution: Try pharmacy consultations for medication adherence issues
4. Measure results: Did A1c control improve?
5. Refine and spread: If it worked, implement more broadly; if not, try something else

Don’t make major changes based on hunches. Test ideas on a small scale first, gather data, then expand what works.

Compare your results to national benchmarks. Learning networks and quality registries show how you stack up against other practices. This outside perspective often sparks new ideas.

Overcoming Common Challenges

Getting Physician Buy-In

Doctors sometimes resist CCM programs. Common concerns include:

• “This is just more paperwork”
• “We don’t have time for this”
• “I’m not convinced it actually helps patients”

How to address resistance:

• Show early wins. Share stories of patients who avoided hospitalization or significantly improved because of the program. Concrete examples beat abstract promises.
• Clarify roles. Emphasize that care coordinators handle the day-to-day work. Physicians oversee but don’t do most tasks themselves.
• Present the data. Show evidence that CCM reduces emergency visits and improves outcomes. This appeals to clinicians’ evidence-based mindset.
• Identify champions. Find one or two physicians who see the value and can influence their peers.

Solving Technology Problems

Technology rarely works perfectly from day one. Common issues include:

• Software crashes or slow performance
• Confusing workflows that staff resist using
• Poor integration between systems
• Difficulty getting data from hospitals and specialists

Solutions:

• Test thoroughly before full launch
• Start with a small pilot group to identify problems early
• Provide robust training and ongoing tech support
• Keep a help desk or super-user available for troubleshooting
• Work with vendors to fix integration issues (and escalate when needed)

Plan for a learning curve. Your first few months will be bumpy. Build in extra support during this period.

Keeping Patients Engaged Long-Term

Initial enrollment is one thing. Keeping patients actively participating is harder.

Why patients disengage:

• Don’t see clear benefits
• Find the calls annoying or intrusive
• Have practical barriers (no phone, unstable housing)
• Cognitive or sensory impairments make participation difficult

Strategies to maintain engagement:

• Build real relationships. Assign the same coordinator to each patient when possible. Familiarity breeds trust.
• Demonstrate value quickly. Help with an urgent concern early in the relationship. When patients experience concrete help, they stay engaged.
• Be flexible. If someone hates phone calls, try messaging. If monthly feels like too much, adjust the frequency.
• Include caregivers. For patients with memory problems or hearing loss, involve family members.
• Show respect. Honor patients’ time. If they’re busy, schedule a better time rather than rushing through the call.

Conclusion: Building a Program That Lasts

Implementing a successful CCM program takes significant effort. You need the right infrastructure, trained staff, solid processes, and ongoing refinement.

But the payoff is substantial. Patients receive the continuous support they need to manage complex conditions. Hospital admissions decrease. Health improves. And your practice builds a sustainable program that works in value-based payment models.

Remember these key principles:

• Start small. Don’t try to enroll 500 patients in month one. Begin with a pilot group, work out the kinks, then expand gradually.
• Focus on relationships. CCM succeeds when patients trust their care coordinator and feel genuinely supported. The human connection matters more than perfect documentation.
• Stay patient-centered. Design your program around what patients need, not just what’s convenient for your workflow.
• Measure and improve. Track your results, identify problems, test solutions, and keep refining.
• Commit for the long term. Building an effective program takes 12-18 months. Don’t give up after a few difficult months.

The healthcare system is changing. Practices that learn to manage population health effectively will thrive. More importantly, you’ll fulfill medicine’s core purpose: helping people live healthier, longer lives with less suffering.

Chronic Care Management isn’t just another billing code or regulatory requirement. It’s a fundamentally better way to care for the patients who need you most.

Ready to Get Started with CCM?

Implementing Chronic Care Management can transform your practice and dramatically improve outcomes for your most vulnerable patients. While the process requires planning and commitment, the rewards—for both your patients and your practice—make it worthwhile.

Want expert guidance on launching or optimizing your CCM program?

Call +1 (727) 214-2749 or email sales@medviz.ai to schedule a consultation. Learn how to streamline your CCM implementation, maximize reimbursement, and deliver exceptional chronic care management that improves patient lives.

Frequently Asked Questions About CCM

Q: What conditions qualify for CCM? Any patient with two or more chronic conditions expected to last at least 12 months and posing significant health risks qualifies. Common examples include diabetes, heart disease, COPD, hypertension, arthritis, kidney disease, and depression.

Q: How much does CCM cost for patients? Medicare covers 80% under Part B; patients typically pay approximately 20% coinsurance (usually $8-15 per month) unless they have Medigap coverage that covers this cost.

Q: What’s the difference between complex and non-complex CCM? Non-complex CCM requires at least 20 minutes per month with standard complexity. Complex CCM requires 60+ minutes per month and involves moderate-to-high complexity medical decision-making for patients with more severe or unstable conditions.

Q: Is CCM only for Medicare patients? While created by CMS for Medicare beneficiaries, some commercial insurers and Medicare Advantage plans now reimburse for CCM services as well. The trend is toward broader adoption.

Q: Can small practices implement CCM successfully? Yes. Start with a pilot program, utilize existing staff, and scale gradually. Many small practices find CCM creates sustainable recurring revenue while improving patient care.

Q: How is CCM different from regular office visits? CCM provides ongoing care coordination between visits—medication management, 24/7 access, specialist coordination, and continuous monitoring. It fills the gaps that traditional episodic care leaves.

Q: What if a patient doesn’t have a phone or internet access? Be flexible. Some patients can be contacted through caregivers, at community locations, or during scheduled in-person check-ins. The key is maintaining regular, documented contact through whatever means work.

Q: How long does it take to see results from a CCM program? Most practices see measurable improvements in patient outcomes within 6-12 months. Financial sustainability typically takes 12-18 months as you refine processes and scale enrollment.