Chronic Care Management

AAFP CCM Toolkit

This CCM toolkit was designed with you in mind. Start increasing your revenue today!

What is Chronic Care Management (CCM)?

The Centers for Medicare & Medicaid Services (CMS) recognizes that chronic care management is a critical component of primary care that promotes better health and reduces overall health care costs. In 2015, using CPT code 99490, CMS began paying separately for non–face-to-face care coordination services furnished to Medicare beneficiaries who have two or more chronic conditions that are expected to last at least 12 months (or until the death of the patient). Examples of covered services include phone calls and emails to a patient to discuss management of chronic conditions, management of referrals to other providers, management of prescriptions, and ongoing review of patient status.

Beginning in 2017, CMS also implemented separate payment for complex chronic care management using CPT codes 99487 and 99489. Complex CCM shares common required service elements with CCM, but has different requirements for the amount of clinical staff service time provided, the complexity of medical decision making involved, and the nature of the care planning performed. Through CPT codes 99490, 99487, and 99489, family physicians and other eligible health care professionals can be reimbursed by CMS for providing CCM services to their patients.

The Academy’s Position on CCM

The Academy’s advocacy efforts helped pave the way for Medicare reimbursement for CCM, giving family physicians an opportunity to be paid for the many services they provide outside of traditional face-to-face office visits. The Academy believes that family physicians should be compensated for the value they bring to their patients by delivering continuous, comprehensive, and connected health care.

What Members Need to Know

Medicare beneficiaries who qualify for CCM services benefit from additional support and resources that help them manage their chronic conditions effectively. More coordinated care leads to better health and decreased overall health care costs. As the health care system transitions from a fee-for-service model to value-based payment, billing CCM services makes it possible for you to be paid for the time and effort you and other care team members invest in caring for your patients who have chronic conditions.

Learn More About CCM with the AAFP CCM Toolkit

Want to be reimbursed for providing CCM services? The AAFP’s Chronic Care Management Toolkit includes the following resources to help you get started:

  • Step-by-step CCM implementation guide for a successful launch
  • Easy-to-use CCM calculator with financial model to determine starting expenses
  • Q&A highlighting important CCM requirements and red flags
  • Side-by-side comparison of the CPT codes for CCM
  • Talking points to help the health care team discuss CCM with patients
  • Talking points to help front office staff and support staff discuss CCM with patients
  • Easy-to-understand patient handout that explains CCM program requirements and benefits
  • CCM consent form for patients who agree to receive services
  • Template for a personalized care plan that helps patients identify action steps to meet their health goals

Buy the AAFP CCM Toolkit »

AAFP CCM Toolkit

This CCM toolkit was designed with you in mind. Start increasing your revenue today!

MediCCM Makes Chronic Care Management Easy

Capture revenue for services you are already providing with MediCCM.

MediCCM seamlessly documents time, creates and updates care plans, and supplements your EMR to help you meet all the criteria required for billing code 99490.

Learn More »(www.mediccm.com)