Participation in a CCM program by primary care physicians remains low.

Now that we appreciate the numerous benefits of starting a chronic care management (CCM) program, both from the standpoint of patient care and reimbursement, while acknowledging some of the reasons behind the hesitation among some providers to initiate one, let’s first discuss the “nuts and bolts” of how to execute such a program. Then, we’ll address practical methods to overcome perceived operational obstacles.

In fact, over the more than five years since the inception of CCM, Medicare has taken significant steps to ease the practical compliance burden for providers. First, the enrollment process has been simplified, no longer requiring written consent. Additionally, several new CPT codes have been added to better capture all the services provided, thereby enhancing reimbursement opportunities. And yet, participation by primary care physicians (PCPs) remains very low.

Let’s go through some recommended implementation steps and strategies, addressing some operational and compliance issues: 

  • Identify eligible patients. Initially identify original Medicare (OM) patients with two or more qualifying chronic conditions, which could be up to 85 percent of your OM population. An electronic health record (EHR) search, combined with targeting appropriate patients on the day of scheduled in-clinic visits, works best.
  • Send a letter/email. Not necessary, but recommended. Alert appropriate patients about CCM, briefly describing the services and the benefits that they can enjoy via enrollment, but also that there could be a copay without a Medicare supplement.
  • Obtain verbal consent. Again, one of the best changes made by Medicare is that written consent is no longer required for enrollment. A brief conversation can be had, either in-person or by phone, with documentation of verbal consent.
  • Identify or hire a staff member. A dedicated person responsible for reaching out to and enrolling eligible patients is needed. This same person can then commence with CCM services. This is most often a remote position, with the minimum suggested professional requirement being that of a Certified Medical Assistant (CMA).
  • Develop a comprehensive care plan. The first step after enrollment is to contact the patient and develop a comprehensive care plan for each condition being followed. These plans should be well-documented, and added to the EHR.
  • Review the comprehensive care plan. The PCP should review the comprehensive care plan, face-to-face with the patient, making any desired changes or adjustments and focusing on the stated methods and goals. Performance of this service not only sets the stage for a well-coordinated CCM program, but it is also a separately billable add-on CPT code (G0506). It can easily be performed at the next scheduled patient visit.
  • Commence/continue with monthly communication. Reach out to all enrolled patients monthly by phone, in addition to text or email, accumulating and carefully documenting time spent for these time-based codes, following the established comprehensive care plans for each condition. These monthly notes should become part of the EHR for the PCP to review as desired; however, this is not a necessary aspect of compliance for billing routine CCM (99490 and G2058).

This list may seem somewhat complicated and cumbersome, perhaps even a bit intimidating. The opportunity might also seem to be limited, from a financial investment standpoint. “Can I actually implement and afford this?” and “Do I completely understand all the compliance issues?” are among the questions you might be asking yourself. They are both reasonable questions.

If we were talking about getting a new home, the issue would be whether to “build or buy.” As applied to this situation, the question is whether to attempt to develop and implement this on your own, or to partner with an outside group that has all the required expertise. Or should the idea be abandoned altogether?

The answer to the third question is an obvious “no,” as we realize that it’s such a terrific opportunity, for all the reasons already stated. But in upcoming articles, we will entertain and answer the others. And we’ll also uncover some of the additional benefits of a CCM program from an ICD-10 coding and HCC/RAF scoring perspective.


Andrew H. Dombro, MD

Dr. Dombro is the Chief Medical Officer for Clarity CCM and is known as a consultant, speaker, and writer. Dr. Dombro provides education for physicians regarding Value-Based Care and CDI improvement.

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