What Conditions Qualify for Chronic Care Management (CCM)?

Chronic care management (CCM) is changing how long-term health conditions are supported, especially within major health systems. With better patient outcomes and measurable experience improvements, CCM is a powerful option—but what exactly qualifies a patient for these services?

Let’s break it down.

Common Chronic Conditions Covered by CCM

The list of CCM-eligible conditions is broad, and even if your specific diagnosis isn’t listed here, your healthcare provider may still determine you qualify. Here are some of the most common categories:

1. Cancer and Oncology Conditions

• Breast, lung, prostate, and colorectal cancers
• Leukemias and lymphomas

CCM supports cancer patients with symptom management, appointment coordination, and treatment tracking during difficult times.

2. Cardiovascular and Blood Disorders

• Hypertension
• Heart failure
• Coronary artery disease
• Atrial fibrillation
• High cholesterol (hyperlipidemia)
• Diabetes
• Anemia

These conditions require ongoing monitoring and lifestyle management—exactly what CCM excels at.

3. Bone and Joint Conditions

• Osteoporosis
• Rheumatoid arthritis
• Osteoarthritis
• Fibromyalgia
• Chronic back pain

CCM helps patients manage pain, mobility, and independence, reducing dependence on caregivers and minimizing ER visits.

4. Eye Conditions

• Cataracts
• Glaucoma
• Diabetic retinopathy
• Macular degeneration

Consistent care planning through CCM can help preserve vision and quality of life.

5. Gastrointestinal Conditions

• IBS
• Crohn’s disease
• Ulcerative colitis
• Chronic liver disease

CCM aids in symptom tracking, diet adjustments, and care coordination with GI specialists.

6. Mental and Neurological Health

• Alzheimer’s and dementia
• Depression and anxiety
• Parkinson’s disease
• Multiple sclerosis
• Epilepsy

These often-overlooked conditions are included in CCM to support both patients and caregivers through continuous care.

Medicare Eligibility Criteria for CCM

Medicare doesn’t publish a fixed list of chronic conditions. Instead, you may qualify if you meet the following:

1. Two or more chronic conditions
2. Conditions expected to last 12+ months
3. Conditions that place you at risk of death, functional decline, or exacerbation

Your provider will assess your situation and submit documentation for Medicare approval.

CCM Documentation Requirements

Recent updates from CMS require:

• A comprehensive care plan, updated at least annually
• Electronic access to the plan by patients and the care team
• Patient consent, which can be revoked anytime
• Minimum 20 minutes/month of documented care to bill for services

Tellihealth ensures these standards are met seamlessly across your practice.

How accuRPM Enhances CCM Results

Pairing CCM with accuRPM, Tellihealth’s remote monitoring platform, strengthens care outcomes:

• Tracks key vitals (e.g., blood pressure, glucose) in real time
• Flags abnormal trends for early intervention
• Encourages patient engagement with health metrics
• Reduces ER visits, readmissions, and hospital stays

Together, CCM and accuRPM create a proactive, patient-centered care ecosystem.

Tellihealth’s Comprehensive CCM Solution

Tellihealth offers a fully managed, concierge-style CCM program that includes:

• Custom care plans for each patient
• 24/7 access to clinical staff
• Real-time remote patient monitoring
• Appointment and medication coordination
• Support for high-risk patients to prevent unnecessary hospitalizations

You don’t have to do it alone—our team works as an extension of your practice to manage chronic care efficiently and compassionately.

Ready to Get Started?

Chronic conditions don’t have to control your life. Tellihealth’s Chronic Care Management services help you or your patients stay healthier, more informed, and better supported.

Concierge value-based CCM is just a click away.
Contact us today to learn how we can help you manage chronic conditions with confidence.