American Association for Physician Leadership

How Partnering with a Chronic Care Management Partner Improves Patient Communication and Coordination for Eligible Medicare Beneficiaries

Janis Coffin, DO, FAAFP, FACMPE

Catherine Van Alstine, BS

Nicollette Leung, MD

Darnelle Ambo, MD

Carla Duffie, MHA, DNP

May 9, 2024

Healthcare Administration Leadership & Management Journal

Volume 2, Issue 3, Pages 103-106


The article discusses chronic care management services that are essential for patients with two or more chronic conditions. CMS has designed a care plan that facilitates communication and follow-up according to the chronic care management codes. The main goals of CCM services are to improve patient experience and satisfaction, patient outcomes, and provider and healthcare worker experiences, and to lower the total cost of care. Chronic care management services make it easier for patients to manage their chronic illnesses, improve communication between patients and providers, and ensure that providers understand their patients’ needs.

Chronic care management (CCM) services have been shown to enhance healthcare outcomes, reduce healthcare costs. and improve patient and provider experiences.(1) CMS has designed a care plan to help improve the lives of both the patient and the provider, by improving communication and facilitating follow-up according to the CCM codes.


For a patient to be qualified to receive CCM services, they must have two or more chronic conditions.(2) A chronic condition is a disease or condition that is anticipated to last for at least 12 months or until the patient’s death.(2) These diseases generally require extensive care and typically continue until the death of the patient. CMS acknowledges that CCM is an essential primary care service that improves the healthcare of a patient and allows them to be able to better financially afford the program.(3) CMS provides an exceptional list of reimbursement codes for providers to use with each CCM visit for patients with multiple chronic illnesses.(4)

The main goals of CCM services are to encourage patients to improve their health while also allowing care to be more affordable and accessible.(3) The CCM visit usually is a non–face-to-face visit, which allows for communication with the patient and his or her family between visits. Patients need to feel supported while their chronic conditions are managed, have a good relationship with the providers they choose, and receive adequate care in which both sides interact with each other and both sides are benefited.(4)


More organized and coordinated care ultimately leads to better health for patients. As of 2015, according to CMS, each patient must have an “initial visit,” which is an in-person appointment with their provider, prior to receiving any services that are provided by CCM. These visits can include an annual wellness visit, evaluation and management, or an initial preventive physical exam.(5) For a visit to be considered an “initiating visit,” the provider must discuss what CCM is and the services that would be given to the patient along with the fees associated with each different kind of service. This visit must have occurred within a year of receiving CCM services.(5) During the visit, the provider makes a standard plan of care that is centered on the patient, and the patient must give their consent, either verbal or written, before they are able to receive any of the CCM benefits or be charged for their services.(3) These initiating visits do not count as part of CCM service; therefore, those services are billed separately.(4) This visit is important, because it improves communication between the provider and patient and ensures that the patient understands exactly: 1) what type of services they will be given through the CCM program; 2) the details on how they will be charged, depending on what type of service they are given each month; and 3) the benefits that they will receive.(4) It is important to note that the patient can suspend their CCM services at any time.(3)

Services that are provided by CCM are coordinated outside of regular office visits for 20 minutes or more each month and are done virtually; services also are available on a daily basis at hourly intervals, year around.(6) During each CCM service, the provider and patient can engage with each other, review the patient’s health information and go over the care plan, updating the care plan electronically and managing any care transitions or other management care services. They also can review medications and all concerns with those, and preventive care (for example bone density screening and cancer screenings such as mammograms) can be arranged.(6) These care plans must be electronically viewed by both the provider and patient along with the billing for each visit.(6) Patients will feel supported with each visit and should feel comfortable confiding in their provider with any concerns they have with either their healthcare plan or services they are given through CCM.

Large health systems that do not have the staff or resources can partner with a third-party supplier that is responsible for the services regarding CCM.(5) Once a patient has been identified as having two or more chronic conditions and is eligible for Medicare, the patient is contacted and talked through the possibility of receiving the services provided by CCM.(5) The people at CCM help with scheduling the patient’s appointments, coordinating care, making sure that the patients are taking their medications as directed, and educating them on how to manage their chronic condition.(6) They also have the ability to contact the hospital’s providers if a patient has any questions or concerns about their plan or care.(6)


CCM ensures that value-based care is directed toward each patient. There are four main goals, all of which aim to benefit not only the patient and their experience but also the provider’s experience as well.(7) This Quadruple Aim ensures that each patient is receiving adequate care and that healthcare workers are receiving a satisfactory experience.(7) The four components of the Quadruple Aim are as follows:

  • Improving patient experience and satisfaction;

  • Improving patient outcome;

  • Improving providers and healthcare workers’ experiences; and

  • Lowering the total cost of care.(7)

Patients expend energy and time keeping up with two or more long-term conditions. CCM services make this easier for the patient. Due to continuity of care, providers are able to come to understand and know their patients on a personal level by building a connection of trust between the patient and provider.(5) Allowing patients trouble-free communication through virtual access with the provider has made managing their chronic illness easier and has made patients more comfortable with treatment due to their reassurance from the provider during their monthly interactions.(5) Trust between the patient and provider is an important factor in ensuring that the patient will receive the best quality of care each month, and this positive relationship that is built between them will motivate patients to want to continue on their healthcare plan.(5)

CCM interactions lead to many positive outcomes, including patient satisfaction, which ultimately increases the patient’s motivation to comply with the care plan. Providers generally report that they have more time to oversee and interact with treatment plans.(5) The fact that patients do not have to come into the office physically allows for more time for direct patient care. Talking virtually allows the provider to have more efficient communication with the patient.(7)

It is important not only to make sure patients receive good quality care but also to ensure that the providers are having a positive experience as well. Burnout has an effect on both physicians and staff members, and they feed off of each other.(7) This results in dissatisfaction with work experience, which can negatively affect the treatment given to patients and is linked with decreased compliance with treatment plans.(7) Virtual appointments save the time, energy, and resources of providers and staff members. Providers are able to discuss treatment plans with patients virtually and still maintain professionalism while giving the quality of care their patients need and being able to treat their patients in a timelier manner.(7) Because providers are able to stay in touch with their patients on a regular basis, the time it takes to respond to problems is reduced. In addition, providers can gather more information about patients’ health and coordinate better care plans that are better suited to the patient.(5)

Medicare is responsible for the costs of 93% of hospitalizations, emergency department visits, and regular health visions of patients with CCM.(5) Implementing standard orders for certain tests will lower the overall healthcare costs.(5) With standing orders in place, not only do physicians save time by not having to put in the orders for these tests, but this also allows for other healthcare members to be able to follow through with specific tasks without requiring the physician to be involved. Patients don’t need a nurse or clerk to check them in and use hospital resources when they don’t have to physically go into the office, which, in turn, will increase revenue through the reimbursements provided through CCM and, thus, lead to better use of resources, ultimately improving patient care.


CMS states that physicians are required to “have a certified electronic health record (EHR)” in order to use the CCM codes to bill for the service.(5) Therefore, although a member of the clinical staff may provide the services for CCM, the only ones who are able to carry out and bill for CCM services are physicians, physician assistants, clinical nurse specialists, and nurse practitioners.(6) Those that are not included in this list must be legally qualified and authorized to give CCM services in the state.(6)

Because chronic conditions require complex care, which takes a lot of time, before CMS updated their billing codes, physicians typically would spend hours of unpaid time outside of office visits ensuring these patients would receive the care they required. In 2015, CMS began reimbursing clinicians through billing codes for these services.(4) These codes are based on the amount of time spent and complexity of each service; the patient must receive at least 20 minutes of service each month in order for Medicare to offer reimbursements.(1) These reimbursement codes allow the provider to bill the insurance according to the specific services rendered,(5) which ultimately leads to an improved and positive provider experience.

In recent years, the billing codes and reimbursements used by CMS have been modified to support timely Medicare reimbursements.(1) To maximize Medicare reimbursements, there is a list of pertinent CCM codes, costs, and descriptions for monitoring patient programs.(1) Each service is documented electronically and recorded for the patient’s EHR.(1)

There are two different CCM codes: standard/non-complex CCM and complex CCM. These cannot be billed in the same month.(8) The main difference between the two is the amount of time spent on the patient’s treatment and the complexity of the case.(6) For a visit to be considered “complex,” there must be a difficult medical decision made by the provider.(6)

CCM codes allow for production of revenue (Table 1). For example, the CPT code 99490 has a reimbursement rate of $62.69 per patient. That is then multiplied by the number of patients served, which will then equal the monthly reimbursement rate.(8) The total reimbursement would then be the annual reimbursement subtracted by the care manager’s annual salary.(8)


CCM services are important and provide benefits that contribute to both patient and provider satisfaction. Efficiency in managing chronic illnesses allows for increased provider services and coordinated patient care plans. Patients have reported that participating in Medicare CCM services has improved their lives and overall care.(5) Partnering with a CCM service allows for providers to use codes to be reimbursed for their time, which, in turn, will maximize patient care through better experiences for both patient and providers alike.(5)


  1. Reddy A, Marcotte LM, Lingmei Z, Fihn SD, Liao JM. Use of chronic care management among primary care clinicians. Ann Fam Med. 2020;18:455-457. .

  2. Chronic Care Management. AAFP website. . Accessed June 28, 2023.

  3. Anderson A. What Is chronic care management? June 29, 2022. . Accessed June 20, 2023.

  4. Wilson C, O’Malley AS, Bozzolo C, McCall N, Ma S. Patient experiences with chronic care management services and fees: a qualitative study. J Gen Intern Med. 2019;34:250-255. . .

  5. Gardner RL, Youssef R, Morphis B, DaCunha A, Pelland P, Cooper E. Use of chronic care management codes for Medicare beneficiaries: a missed opportunity? J Gen Intern Med. 2018;33:1892-1898. . .

  6. Chronic Care Management Services. Medicare Learning Network. 2022.​-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf . Accessed June 20, 2023.

  7. Fink-Sammnick E. Professional resilience paradigm meets the quadruple aim: professional mandate, ethical imperative. Professional Case Management. 2017;22:248-253. .

  8. Chronic Care Management CPT Codes: 99490, 99439, 99487. ThoroughCare. February 1, 2023. Accessed June 18, 2023.

Janis Coffin, DO, FAAFP, FACMPE

Janis Coffin, DO, FAAFP, FACMPE, Chief Transformation Officer, Augusta University, Augusta, Georgia; email:

Catherine Van Alstine, BS

Catherine Van Alstine, BS, Patient Care Assistant, Augusta University, Augusta, Georgia.

Nicollette Leung, MD

Nicollette Leung, MD, Family Medicine Resident Physician, Medical College of Georgia at Augusta University, Augusta, Georgia.

Darnelle Ambo, MD

Darnelle Ambo, MD, Resident Physician, Family and Community Medicine, Augusta University, Augusta, Georgia.

Carla Duffie, MHA, DNP

Carla Duffie, MHA, DNP, Nurse Manager, Family Medicine, Augusta University Health, Augusta, Georgia.

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