What is chronic care management?

Chronic Care Management (CCM) is defined by the Centers for Medicare and Medicaid Services (CMS) as coordinating care for patients with multiple chronic conditions outside regular office visits. These conditions are expected to last at least 12 months or until the patient passes away.

What are the benefits of chronic care management?

CCM helps practices create personalized care plans, improve adherence to care guidelines, streamline documentation, and support a more efficient billing workflow. The goal is to improve outcomes, reduce complications, and stay aligned with CMS requirements.

How does chronic care management work?

CCM typically includes patient enrollment, creation of a care plan, ongoing monthly care coordination and patient communication, and accurate documentation for billing and reimbursement.

What services are included in chronic care management?

CCM services can include identifying chronic conditions, developing care plans, coordinating referrals, reviewing results, medication support, documenting monthly communication time, and recording billable actions for compliance.

What are Chronic Care Management CPT codes?

CCM CPT codes are billing codes used to report chronic care management services. Common codes can include 99490, 99439, 99487, 99489, 99491, and related codes, depending on the service level and time.

How do Chronic Care Management CPT codes work?

Practices use CCM codes to bill for specific care coordination services based on eligibility, documented activities, and time thresholds. Proper documentation supports accurate reimbursement and transparency for the care delivered.

RPM & CCM Insights: Why Patients Refuse Care?

Jessica Carter MS, RDN, LN
September 23, 2022

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Why Do Patients Resist Change

Change provokes strong emotions regardless of personal desire. Some individuals embrace change and look forward to its outcome. Others fear and avoid it like the plague. Regardless of one’s personal feelings towards life’s turning points, one thing remains the same: change is an inevitable part of life. Despite the futility of resisting, many patients will fight against change as hard as they can, when in fact that effort would be better served in simple acceptance.

Everyday patients face changes that impact their personal wellbeing. Some of these reversals come from an influence of external forces, while others are the direct result of choices made by the patient. Although change is consistent and consistency can be comforting for some, more often, with change there is typically a feeling of loss of control and a sense of vulnerability. In healthcare physical change happens organically as the body advances in age and can be a swift reminder of the fragility of life.

Change as opportunity

But change is not always happening in the background. Sometimes the patient is the driver of change and, rather than an inevitability, it is an opportunity and valuable tool that is implemented to manage chronic disease or prevent further ailments. Making lifestyle and wellness-related changes often requires a commitment to accepting that one’s health is in a state requiring something different to manage the passive change that is already occurring.

Resistance to change

Accepting one’s limitations is difficult during the best of times but nearly impossible when dealing with chronic disease. For some patients, resistance to change is as simple as denial for their current condition. For others resistance to change is a form of procrastination, or not prioritizing their health and wellness. This resistance shows up as pushing things off to another day because there are too many other pressing matters. Resistance to change also stems from stubbornness or an unwillingness to acknowledge a lack of knowledge around what is best for their health. It is a form of defense against the unknown.

Positive approach to facing change

Resistance to change manifests in several ways including excuses, denial, and avoidance. Ultimately accepting change requires awareness, acceptance, humility, and strength to face what is ahead. When trying to encourage change, providers benefit from integrating ccm into their practice allowing them to focus on a patient’s strengths and foster feelings of empowerment in their conversations. An example of this is discussing specific examples of what has worked for them in the past, and accentuating those positive experiences. Coaching is a method that allows the patient to drive the change thus tamping down their own resistance by the simple act of being in control.

Schedule a Discovery Call

Are you interested in learning more about RPM Logix’s CCM and RPM solutions for better patient care and how it uses coaching tools as part of its Care Team strategies for your patients?

RPM Logix features a Care Team staffed with Nurses, Diabetes Educators, Exercise Physiologists, and Registered Dieticians. To learn more, schedule a discovery call today.

Jessica Carter MS, RDN, LN

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Disclaimer

The information provided by RPM Logix is intended for educational purposes only and should not be construed as legal or medical billing advice. While every effort is made to ensure the accuracy and timeliness of the content, RPM Logix makes no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability of the information provided. The coding and billing guidelines, including but not limited to CPT, HCPCS, and ICD codes, are subject to updates and changes by regulatory authorities such as CMS (Centers for Medicare & Medicaid Services) and the AMA (American Medical Association).
RPM Logix is not responsible for any errors, omissions, or outcomes resulting from the use of this information. It is the responsibility of the healthcare provider to verify the accuracy of coding and billing information, to remain informed about updates, and to comply with all relevant payer guidelines and regulations. RPM Logix strongly recommends consulting legal counsel, reimbursement specialists, or the appropriate authoritative resources before submitting any claims.
By using the information provided by RPM Logix, you acknowledge and agree that RPM Logix shall not be held liable for any claims, damages, or other liabilities arising from your use of the information, including but not limited to any billing, coding, or reimbursement issues that may result from reliance on the material presented.

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