CCM comprises up to 85 percent of the Medicare beneficiary population.

With chronic care management (CCM) representing such a tremendous opportunity to help your most at-risk patients while also boosting your Medicare reimbursement, it begs the question: why wouldn’t a provider want to implement it?

CCM services are personal, remote interactions done outside of and between routine office visits. Initiated by Medicare in 2015, this collection of services is performed by ancillary staff under general supervision of the provider, designed for patients who are at the highest risk for poor clinical outcomes: those with two or more chronic medical conditions. By many conservative estimates, this comprises up to 85 percent of the overall Medicare beneficiary population.

The fundamental guiding principle of CCM is that with better disease management and coordination of care, adverse clinical outcomes can be largely avoidable within this population. At a basic level, such services are designed to enhance patient satisfaction and well-being: a predictable result, when patients better understand and feel that they have control over their chronic medical conditions. And at a much more profound level, if we can significantly improve clinical outcomes by decreasing the rates of emergency department (ED) visits and hospitalizations, and help prevent disease progression and even death, then shouldn’t we?

One of Medicare’s ultimate goals, without sacrificing quality of care, is to decrease costs and to limit spending, mainly by way of decreasing these avoidable ED visits and hospitalizations. Patients with two or more chronic conditions account disproportionately for both. In this case, it is very much a “spend money to save money” situation, as Medicare is willing to provide reimbursement to providers who choose to utilize these services, by way of an assortment of new CPT/HCPCS codes.

How does Medicare define which chronic conditions qualify for these services? There is a somewhat helpful listing of chronic conditions on the Centers for Medicare & Medicaid Services (CMS) website, (the Chronic Conditions Data Warehouse, available online at, but this is more of a research database, and is not intended to be an all-inclusive list. Any chronic condition that is “expected to last at least 12 months or until the death of a patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline” would technically qualify. In other words, it is based on provider judgement.

So, what this amounts to is a situation in which providers can significantly improve the quality of care they provide to their sickest patients, increasing their satisfaction, health, and well-being, making in-office visits more efficient and beneficial, while largely keeping them out of the ED and the hospital. At the same time, engaged providers can positively and directly affect their Medicare reimbursement – while also improving measured patient outcomes and thereby boosting MIPS (Merit-Based Incentive Payment System) scores. It’s a rare but definite “win-win-win” situation.

But as always, the news is mixed. The good news is that early studies have demonstrated that where these services have been utilized, there were decreased ED visits and hospitalizations, with greater patient satisfaction and health benefits, as well as reduced costs. The bad news is that despite this, providers have largely not implemented CCM. And this has changed very little over time, even though Medicare has added codes to help capture the provision of these services, while also making the enrollment process much easier and straightforward. What’s more, the providers that do implement CCM services are commonly underutilizing them, and sometimes even failing in their attempts.

The reason(s) providers are not incorporating these beneficial and lucrative opportunities into their primary care practices are varied, but generally fall into one (or more) of three typical categories:

  • Lack of knowledge about the existence of these initiatives;
  • If there is knowledge about them, a failure to understand how to actually implement them, either from a compliance or a logistical standpoint (or both); and
  • If there is a recognition of these initiatives and a basic understanding of how to implement them, then there is the perception that to do so would be cost-prohibitive (i.e., carrying too much financial risk).

In follow-up articles, we’ll discuss how to reasonably address these and other issues, as well as how to gain understanding of all the compliance aspects of CCM, so that most primary care practices will be able to (and should) participate … with some help!

Programming Note: Listen to Dr. Andrew Dombro report this story live today during Talk Ten Tuesdays, 10-10:30 a.m. EST.


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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