Chronic care management (CCM) is a remote care program designed to provide comprehensive and coordinated care for individuals living with multiple chronic conditions and comorbidities. It is a proactive and patient-centered strategy that focuses on improving outcomes, quality of life, and lowering costs for patients in the program. Unlike traditional episodic care, where healthcare providers primarily address acute symptoms or immediate health concerns, chronic care management takes a holistic and long-term perspective for some of the most serious health conditions.

At its core, chronic care management recognizes that chronic diseases are often complex and multifaceted, requiring ongoing monitoring, treatment, and support. These conditions typically persist for an extended period and may require primary care interventions related to both medical & social determinants of health (SDOH), as well as a combination of lifestyle modifications, community resources, and patient education. Chronic care management aims to bridge the gap between healthcare visits and empower patients to actively engage in their own care.

Key Elements of Chronic Care Management:

Care Coordination:
One of the fundamental aspects of chronic care management is the coordination of healthcare services across multiple providers and settings. This includes primary care physicians, specialists, nurses, pharmacists, caregivers & family members, and other healthcare professionals involved in the patient’s care. Proper and timely care coordination ensures that information flows smoothly, treatments are aligned, and the patient receives consistent and cohesive care.

Personalized Care Plans:
Chronic care management emphasizes the development of personalized care plans tailored to each patient’s unique needs and circumstances. CCM care plans are living documents, routinely updated, that outline specific goals, treatment strategies, and self-management techniques to address the individual’s chronic condition effectively. They take into account factors such as the patient’s medical history, physician’s notes, SDOH needs, lifestyle, preferences, and social support network.

Regular Monitoring and Follow-up:
CCM involves regular monitoring and follow-up to track the patient’s progress, adjust treatments as necessary, and deliver timely primary care interventions. This may include scheduling office & same-day sick visits, facilitating completion of annual wellness goals, performing required assessments, medication reconciliation, telehealth consultations, remote monitoring technologies, and frequent communication between the patient and their healthcare team. Continuous monitoring helps detect changes in the patient’s health status, enabling timely interventions and proactive management.

Patient Education and Self-Management:
Empowering patients with knowledge and skills to manage their chronic conditions is a crucial component of chronic care management. Education on topics such as medication management, symptom recognition, healthy lifestyle choices, and coping strategies equips patients with the tools to actively participate in their care. By promoting self-management, chronic care management aims to enhance patient engagement, improve treatment adherence, and foster a sense of control over their health.

Engagement of Providers & Practice Staff:
Effective chronic care management relies on the active engagement of healthcare providers and practice staff. They collaborate effectively to deliver patient-centered care, receive specialized training, ensure efficient communication, and embrace technology for improved patient outcomes. This engagement enhances care coordination and strengthens the overall CCM process.

What is Chronic Care Management to Patients?

To patients, when CCM is implemented properly, enrolling in a chronic care management program means access to a dedicated nurse, connected directly to their primary care physician, providing personalized care on a monthly basis to help them better manage their conditions in between office visits to avoid ending up in the ED. CCM aims to support patients in becoming more engaged in their healthcare from the comfort of their home.

CCM engages patients longitudinally with a structured and coordinated system of care that addresses both immediate symptoms and long-term management of their condition. Successful CCM nurses collaborate effectively with the patient’s care team to develop personalized care plans tailored to patient’s medical history, SDOH needs, lifestyle, preferences, and goals.

Patients enrolled in a CCM program feel more connected to their primary care physician, are empowered to manage their chronic conditions proactively, receive timely primary care interventions, and have a reduced risk of ED visits and/or hospitalizations.

What Reimbursements Are Available for CCM Services?

In 2025, the Relative Value Unit (RVU) Multiplier for all services and treatments billed to Medicare is $32.05. This is a slight decrease from 2024. But it’s important to remember that RVU-based conversions also vary by both: 

1. Clinical specialty, and
2. Geographic locations of facilities

That said, here is a table of 2025 CPT codes for CCM treatments and average rates:

2025 CCM Reimbursement Rates
CPT Code	WHAT IT COVERS	2025 RATE
99490	The first 20 minutes of clinical chronic care management services for patients with two or more chronic conditions lasting 12 or more months.	$62.58*
99439	Each additional 20 minutes of clinical time directed by a healthcare professional for chronic care management services.	$47.93*
99491	At least 30 minutes of chronic care management services, delivered by the billing provider, for patients with two or more chronic conditions expected to last 12 or more months.	$83.18*

*actual reimbursement varies by region.

More details on 2025 CCM reimbursements can be found here on the Signallamp website.

What is the Goal of Chronic Care Management?

The primary goal of chronic care management is to improve patient quality, patient experience, and lower total cost of care for patients living with multiple chronic conditions and comorbidities. The overarching objectives include:

• Improved Health Outcomes & Lower Costs: CCM has been shown to help improve outcomes, enhance patient experiences, and lower costs across enrolled populations by implementing evidence-based practices, regular monitoring, and proactive interventions.
• Enhanced Patient Engagement: Successful CCM emphasizes patient engagement by involving them in treatment decisions, providing education, resources, and creating meaningful connections between patients and care teams.
• Care Coordination and Continuity: CCM improves efficient information sharing, aligned treatments, and cohesive patient management across healthcare providers.
• Preventive and Proactive Care: CCM helps reduce hospitalizations, emergency room visits, and other avoidable healthcare utilization through regular monitoring, early detection, and timely interventions.
• Improved Patient Satisfaction: CCM enhances patient-provider relationships by providing personalized and comprehensive care that meets individual patient needs and preferences.

Is Chronic Care Management Worth It for Healthcare Providers?

Yes. Chronic care management programs like signalCCM, powered by Tellihealth, provide clear value by improving population health management, generating cost savings, enhancing patient engagement, ensuring better care coordination, and increasing patient satisfaction. By investing in CCM, healthcare providers can deliver more comprehensive, patient-centered care, improving overall outcomes.

What Diagnoses Qualify for CCM?

CCM typically includes chronic conditions such as diabetes, hypertension, CHF, COPD, asthma, CKD, mental health conditions, and other chronic diseases, potentially covering approximately 75% of Medicare patients.

Interested in CCM?

For Health Systems and Physician Groups interested in learning more about signalCCM, powered by Tellihealth, schedule time to talk with us today!