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Chronic Care Management Workflow

Do you have a medical practice that doesn’t fully understand the chronic care management workflow? You are not alone, and this guide will specifically touch all corners of chronic care management and its corresponding medical billing workflow. Furthermore, suppose your healthcare practice is looking to improve patient services and increase value-based reimbursement. In that case, the chronic care management program (CCM) from CMS (Centers for Medicare & Medicaid Services) can help you achieve such goals.

Understanding Chronic Care Management Workflow (CCM)

The CCM or chronic care management workflow is about serving patients under Medicare with two or more chronic conditions. CCM acts as a preventative service in assisting Medicare patients to take on a proactive approach to their health and wellness outcomes. All of this is possible while keeping them attached to their healthcare providers.

Importance of Chronic Care Management

Recent statistics suggest that over 80% of chronic diseases can be eliminated via preventative measures. Furthermore, two-thirds of all deaths in the USA are attributed to one of the 5 major chronic disorders, and these include:

  • Diabetes
  • Cancer
  • Chronic obstructive pulmonary disease
  • Stroke
  • Heart disease

A comprehensive CCM program can assist your practice in offering earlier interventions in the patients, encouraging compliance with the medication regimens, supporting lifestyle improvements, and decreasing the number of hospitalizations, unnecessary ER visits, and other complications your patients may face.

Guidelines for Smooth Chronic Care Management Workflow

How can your practice ensure you follow chronic care management workflow program guidelines and offer quality care? Read the 6 essential steps below for ensuring effective CCM.

1. Understand Who Can Bill for Services

The first step in understanding the chronic care management workflow is knowing who can participate in chronic care management billing. In addition to the physicians, the following non-physician practitioners can also bill for the CCM services:

  • Clinical nurse specialists
  • Physician assistants
  • Certified nurse midwives
  • Nurse practitioners
  • FQHCs (federally qualified health centers)
  • RHCs (rural health clinics) and hospitals are also eligible

2. Recognizing Patient Eligibility

When you move towards determining which type of patients will qualify for enrollment in a CCM program, it is vital to keep the below requirements in mind:

  • Patients must have two or more of the chronic conditions.
  • These conditions must be expected to last at least 12 months.
  • These conditions must place patients at substantial risk of acute exacerbation, decomposition, death, or functional decline.

CMS offers the below examples of adequate chronic conditions, including:

  • Cancer
  • Alzheimer’s
  • Dementia
  • COPD (Chronic obstructive pulmonary disease)
  • Cardiovascular disease
  • Diabetes

3. Comprehensive Care Plans for CCM

The practitioners and carriers must have comprehensive patient care plans to meet the CCM criteria. By expanding these care plans, healthcare practices can provide person-focused or personalized care.
What should a care plan include?

  • Complete assessment or reenactments of a patient’s mental, physical, and psychosocial needs
  • A comprehensive list of health problems, especially emphasizing the chronic conditions
  • An outline of treatment goals and the expected outcomes
  • Record of individuals and resources that are involved in care
  • Medication management (ongoing)

It is essential to make these plans easily accessible to caregivers and patients. It is also vital to be available to other healthcare providers if and when needed. Furthermore, healthcare practices and providers can also use a patient portal for patients to access the electronic copy of their care plans readily.

4. Obtaining and Documenting Patient Consent

Before billing or even offering the CCM services, healthcare practitioners must obtain a patient’s verbal or written consent. Furthermore, this consent must be documented in the medical records. When inviting or welcoming patients to participate in a CCM program, make it clear that they can opt-out anytime. Furthermore, it informs patients that only one practitioner can offer these monthly services. Additionally, it is vital to discuss with patients what they expect from CCM and any other applicable cost-sharing.

5.Tracking Time

As a part of the chronic care management workflow, healthcare providers must track the time for non-face-to-face services for every CCM patient. Patient prescription management, calls to patients, medication reconciliation, and care coordination with other healthcare facilities and practitioners are a few examples of time-tracking duties.
Healthcare practices may even employ chronic care managers to oversee care coordination, education, and coaching.

6. Partnering with Care Coordination Services

If your practice is interested in the CCM program, but your staff is already too burdened to tackle the chronic care management workflow, consider outsourcing the CCM medical billing workflow to a third-party billing provider like Physicians Revenue Group, Inc.

Key Advantages of Chronic Care Management

Healthcare facilities today already have too much on their plates, and it is difficult to imagine giving your staff more work, even when that can help your patients. The good news is that CCM services are simple and easy to implement. Furthermore, when done correctly, efficient CCM programs offer healthcare providers valuable insights into their patients and create a streamlined approach to patient care.
Further avenues where a CCM program can help providers:

  • An efficient chronic care management workflow that improves response time when issues arise. It is possible by maintaining frequent contact with patients, assisting your team to identify new developments in patients’ health, and pinpointing high-risk patients.
  • The pre-empt condition, which can result in acute care circumstances
  • By easily connecting with your patients, you can create a trusted relationship via monthly conversations that empathize and even improve understanding of the unique healthcare challenges of a patient.
  • Preventing acute situations through gathering detailed information from patients to locate health deficiencies. It can be possible by establishing a trusting relationship during patient-caregiver monthly calls and letting patients express their ideas and concerns about their care.
  • Increasing the practice revenue via CMS reimbursements leads to more budget for the additional staff and resources for improving patient care.


Understanding the chronic care management workflow is vital as it presents a transformative opportunity from the CMS to improve healthcare services. Adhering to the necessary workflow guidelines, healthcare providers can improve patient care massively and enhance their practice’s financial stability. The strategic CCM approach addresses the urgent challenges of chronic diseases and facilitates providers in fostering stronger patient relationships, making informed decisions, and securing additional resources for making high-quality care possible.

Frequently Asked Questions

The CCM services include personalized care from dedicated healthcare professionals, offering round-the-clock emergency access to healthcare professionals, in addition to coordination of care between:

  • Hospitals
  • Testing centers
  • Specialists
  • Pharmacies, and more.
The essential criteria to fall under the CMS CCM program is having two or more chronic conditions that may last for 12 months or until the death of a patient.

Benefits of outsourcing medical billing services are:

  • Outsourcing of healthcare billing facilitates more focus on patient care.
  • Third-party billing services reduce the administrative duties of healthcare staff.
  • It enhances cash flow.
  • Outsourcing also reduces billing errors.



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