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.

Chronic Care Management Solutions in Tennessee

We improve chronic care and weight loss outcomes through patient engagement, coaching, and remote patient monitoring, while increasing provider revenues and enhancing quality of care.

Learn How RPM Logix Can Elevate Your Practice

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What Makes Us Different

Unlock Chronic Care Management (CCM) in Tennessee

The most underutilized program in CMS history.

What Do Your Practice’s CCM Numbers Look Like?

The Center for Medicare and Medicaid Services(CMS) wants to help. In 2022, to incentivize higher utilization, CMS INCREASED reimbursement +51% and +25% for the 2 main CCM Codes 99490 and 99439.

Are you utilizing the higher reimbursement complex Chronic Care Management codes 99487 and 99489?

Let our Care Team integrate these higher reimbursing codes into your CCM Program.
Here are the reimbursements:

Learn why CCM is the asset your practice may need.

	CHRONIC CARE MANAGEMENT CPT CODES
99490	Minimum 20 cumulative minutes over a 30-day period of non-face-to-face time monitoring the care plan.	$62.69
99439	Subsequent 20 minutes of care provided by clinical staff.	$47.44
99439	Subsequent 20 minutes of care provided by clinical staff.	$47.44
99491	Initial 30 minutes of care personally provided by physician, or non-physician practitioner (NPP).	$86.17
99491

99437	Subsequent 30 minutes of care personally provided by a physician or NPP.	$61.25

	COMPLEX CHRONIC CARE MANAGEMENT CPT CODES
99487	Minimum 60 cumulative minutes over a 30-day period of non-face-to-face consultation time establishing or monitoring a care plan.		$133.18
99489	To be billed with CPT 99487 for every additional 30 minutes of non-face-to face consultation.		$70.49

Outsourcing chronic care management with RPM Logix is simple, effective, scalable, and profitable. A more sophisticated yet simple data approach to CCM

Our nurses emphasize the “care” in Chronic Care Management (CCM). Here’s a list of activities we routinely perform. Let us construct a reimbursable concierge service that will delight your patients, improve outcomes, and generate well-deserved income for your practice.

CCM AS A CONCIERGE SERVICE
A Care Team nurse will expertly assist patients on all of their healthcare needs
Schedule appointments for all doctors
Organize health records
Monthly medication reconciliation
Enter med refills
Provide education on all chronic conditions
Monthly 20-minute health check
Make appointments for transportation to office
Weight loss with a registered dietitian
Healthy heart diets
Diabetes prevention and education
Triage patient calls, and contact physician only when issue is actionable.
Provide patient with an ongoing customized care plan
Catalog all resources for patients on their private microsite

Remote Patient Monitoring & Chronic Care Management Support Groups and Webinars in Tennessee

Why support groups?

With multiple chronic conditions, many patients today are challenged by navigating the gap between their periodic medical visits and learning how to cope with their conditions day-to-day. The reality of today’s office visits is that they don’t often afford the emotional support needed to cope. Friends and family, even when available, may not understand the impact of treatments needed.

Benefits of support groups:

Feeling less isolated
Stress reduction
Discovering they’re not alone with these conditions
Learning how to cope with challenges
Fresh motivation to improve
Enabling sense of control
Better medication compliance and care plan adherence
Learning about available local resources

Boost Revenue with RPM Logix’s & CCM AI Tools

RPM Logix utilizes an artificial intelligence (AI) algorithm that tracks patient billing progress throughout the month. We factor in allowable minutes based on the patient’s insurance, and which programs they’re enrolled in.

Scenario 1

We’re approaching month-end. An RPM patient has 61 minutes documented, and has an insurance cap of 80 minutes. The patient is due for a 10-minute education follow-up call. If that 10-minute call is placed on the last day of the month, it will not be billable because no minutes count until the next billable threshold (80 minutes is met). The RPM algorithm will schedule that next elective phone call for a day later at the beginning of the new month, when it will be fully billable.

THIS IS ONLY DONE FOR ELECTIVE PHONE CALLS. ANY PATIENT CALLS OR READING ALERTS WILL ALWAYS BE RESPONDED TO IMMEDIATELY.

Scenario 2

A Medicare patient is dual-enrolled in RPM and CCM programs (specifically permitted in the CMS rule: as long as minutes for each program are clearly separated, RPM Logix software assures compliance). The patient has an 80 minute cap on their insurance allowable for RPM, and 60 minutes for CCM, and is seeing our diabetes educator for diabetes prevention. A total of 100 minutes for the month is documented. RPM Logix will record the first 80 minutes under RPM, and document the spill-over 20 minutes into CCM. Education is optimized, and reimbursement is optimized as well – all while staying 100% compliant.

Scenario 3

Avoid the February billing trap. CMS rules specify that RPM time-based codes 99457 and 99458 can only be billed once per calendar month. This means the date of service can be any day of the month.

CPT code 99454 for monthly device readings has a DIFFERENT RULE. It can only be billed after a 30-day interval has elapsed from the prior month’s date of service for this code. Let’s say your January date of service is January 31. Come February, if you submit the 99454 claim with date of service Feb 28, it will be rejected!

RPM Logix’s algorithm will push the next date of service to March 2, so you’ll be in compliance with this 30-day interval requirement. Subsequent months’ dates of service will also be adjusted so you won’t have claims rejected for procedural errors.

After each month-end, RPM Logix will provide you with a COMPREHENSIVE Billing Report to capture all billable activity, and assure compliance. Everything that’s required for accurate billing is on the report- Name, DOB, ICD-10 Diagnosis Codes, CPT Codes with accurate units noted for add-on codes. The all important date of service is listed as well. This is critical. While RPM and CCM share monthly billing cycles, certain codes with their add-ons must show the same date of service or they’ll be rejected.

355,989,051

Total Medicare Part B beneficiaries in the US

22,570,401

Medicare beneficiaries with 2+ chronic conditions eligible for CCM services

63.4%

Percentage of Medicare beneficiaries eligible for CCM

4%

Percentage of eligible beneficiaries with CCM claims

You have the option to customize and brand your CCM program or RPM program with a theme that sparks your patient’s motivation.

CCM and RPM offered as a Medicare VIP program

CCM and RPM weight loss program

CCM and RPM offered as a diabetes education program

Getting patients signed up for RPM and CCM is easy. Providing value so they stay enrolled long-term is the challenge. RPM Logix’s Care Team keeps patients engaged for the long run, and is a huge asset to our practice.

Dr. Meyer Abittan

Abittan Heart Specialists

RPM Logix has branded a hugely successful weight loss program for us that’s offered to all CCM and RPM patients.

Dr. Ola Akinboboye

Laurelton Heart Specialists

RPM Logix is a straight-forward organization. They provide excellent patient care. Their detailed reporting allows me to track patients results in-between office visits. Their fees are very reasonable.

Dr. Michael Richter

Rego Park, New York

See How RPM Logix Can Help You

Clinical Service	How We Improve Outcomes		How We Increase Income
Credentialed Care Team
Nurses
Nurses
Registered Dietitians


ADCES Diabetes Educators
Integrate with Over 560 Devices
CGM’s (Continuos Glucose Monitors)
AI Biometrics on Smartphones
Weight Loss Support Groups
Diabetes Support Groups
Diabetes Prevention Program
Monthly Patient Webinars
Patient Microsites
Behavioral Health Integration
Annual Wellness Visits
Patient App

Concierge Services	How We Improve Outcomes		How We Increase Income
Appointment Scheduling
Return Clinical Calls
Return Clinical Calls
Lab Report Discussions


Scheduling In-House Diagnostics
Patient Navigation with Specialists / Hospital
Help Patients Obtain DME

Admin Services	How We Improve Outcomes		How We Increase Income
Comprehensive Billing Reports
Outsourced Patient Enrollment
Outsourced Patient Enrollment
Device Shipping to Patients


Device Customer Service

CCM VS RPM

IMPROVING OUTCOMES	RPM		CCM
Regular disease specific assessments
Patient Centered Care Plan
Integrate with 550+ Devices
AI-driven Smartphone App
Dexcom and Abbott Libre Device Option
Population Health Reporting
Care Team Staffed with Nurses
Motivational Interviewing Techniques
Diabetes Educators
Registered Dieticians
Behavioral Health Integration
Medicare Annual Wellness Visits
Personalized Patient Microsites
Patient Webinars
Weight Loss Support Groups
Sugar Busters Support Groups

PROACTIVE FINANCIAL RESULTS	RPM		CCM
100% Documented Audit Trail
Fully Scrubbed Billing Reports
Practice-Branded Marketing Programs
Weight Loss Program
Diabetes Education Program
Healthy Heart Program
Diabetes Prevention (DPP)
Monetize Previously Unreimbursable Admin Tasks Rx Refills Appointment Scheduling Diagnostics Scheduling
Call Schedule Algorithm that Increases Revenue

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Chronic Care Management Solutions in Tennessee

We improve chronic care and weight loss outcomes through patient engagement, coaching, and remote patient monitoring, while increasing provider revenues and enhancing quality of care.

Learn How RPM Logix Can Elevate Your Practice

What Makes Us Different

Full Service Model

Reimbursable Clinical Programs

Credentialed Care Team

Flexible Device Platform

Customized Microsites for Each Patient

Population Health Analytics

Audit Proof - Billing Reports