Chronic Care Management (CCM)
What is Chronic Care Management?
Chronic Care Management (CCM) refers to a healthcare delivery model designed to provide continuous, coordinated care for individuals with chronic medical conditions. The Centers for Medicare and Medicaid Services (CMS) recognizes CCM as a critical primary care service contributing to better patient health and care. Chronic conditions typically require ongoing management, monitoring, and support over an extended period.
Order Patients a Device
We provide patients 4G devices that monitor blood pressure, glucose, pulse ox and/or weight. Devices send data back to our platform in real time.
Respond to
Abnormal Readings
When patients have abnormal readings, our 24/7 clinical team of nurses will call you patient, assess, and escalate relevant cases to the appropriate provider.
Bill the Payer for RPM/CCM
Our clinical team’s interactions with your patient generate time towards the time-based RPM/CCM codes that you will bill monthly. We generate the billing reports each month and provide them to your billing department.
What devices do you use?
Who monitors the patient data?
Our Clinical Team
Our clinical monitoring team of nurses and MAs monitors your patients 24/7, responding to readings, calling, assessing, and escalating relevant cases to you.
How much will get reimbursed for CCM?
Up to $160 per patient, per month.
Monthly
20 Minutes – CCM
99490: Initial 20 minutes of clinical staff time. Average $64.
40 Minutes – CCM
99439: Subsequent 20 minutes of clinical staff time. Average $48.
60 minutes – CCM
99439: Subsequent 20 minutes of clinical staff time. Average $48.
How much will get reimbursed for RPM?
Up to $193 per patient, per month.
First Month
Initial Enrollment
99453: Initial patient setup and enrollment into RPM program. Average $20.
Monthly
Base Monthly RPM
99454: Remote monitoring and management of device readings. Average $55
Monitoring (20 mins)
99457: 20 minutes of clinical staff time communicating with patient or caregiver. Average $50.
Monitoring (40 mins)
99458: Additional 20 minutes of clinical staff communication with patient or caregiver. Average $44.
Monitoring (60 mins)
99458: Additional 20 minutes of clinical staff communication with patient or caregiver. Averages $44.
How will this benefit our patients?
-16 mgdl
Our clinic’s average blood glucose improvement overtime
-11 mmHg
Our clinic’s average blood glucose improvement overtime
-9 mmHg
Average diastolic blood pressure improvement overtime
-4 bpm
Average resting heart rate improvement overtime
-17 lbs
Average weight loss improvement overtime
22%
Average weight loss improvement overtime
How will you keep our patients engaged?
Automated Reminders
In addition to our live agents who call patients, our automated reminder system will send SMS reminders to patients to remind them to take their readings.
Consumables Included
We supply patients with consumables for their devices, including batteries, diabetic lancets and test strips as part of our service.
Care Coordinators
When enrolled in our CCM program, every patient will be assigned their own personal care coordinator. Developing a trusting, and meaningful relationship with patients will ensure long-term adherence.
How do we get started?
Receive Analysis
Receive a complimentary analysis of how many patients qualify for RPM and CCM, along with your estimated costs and reimbursement.
Ship Devices
Once patient consent has been obtained, will ship devices and consumables to your patients’ homes.
Get Reimbursed
We’ll provide a monthly billing report so your biller can easily generate RPM and CCM claims.
Get Consent
Our team will call patients to educate them about RPM and CCM and obtain their consent.
Monitor
Our RNs will call your patients when their readings are abnormal and escalate appropriate ones to your attention.
