In today’s evolving healthcare landscape, managing patients with multiple chronic conditions requires more than just periodic office visits. That’s where Chronic Care Management (CCM) steps in—a Medicare-supported program designed to improve care continuity, reduce hospitalizations, and support better health outcomes through structured, ongoing engagement.
What is Chronic Care Management (CCM)?
Chronic Care Management refers to non-face-to-face services provided to Medicare patients with two or more chronic conditions that are expected to last at least 12 months or until the patient’s death. These conditions can include diabetes, hypertension, heart disease, arthritis, and more. The goal of CCM is to help patients manage their conditions through coordinated care that extends beyond the exam room.
Under the CCM model, healthcare providers or care coordination teams engage patients monthly by phone or secure technology, monitor their progress, provide health education, ensure medication adherence, and adjust care plans as needed. This regular touchpoint helps patients stay on track, catch warning signs early, and avoid costly complications.
How Does CCM Benefit Providers and Patients?
For patients, CCM means greater support between visits, a personalized care plan, and a team actively monitoring their progress. It leads to improved medication adherence, reduced emergency visits, and a stronger understanding of their own health.
For providers, CCM offers a new revenue stream through Medicare reimbursement—without the need for additional in-clinic visits. Practices can bill for 20+ minutes of clinical staff time per patient, per month, under CPT code 99490 and related codes. When implemented well, CCM strengthens patient trust, enhances outcomes, and improves overall care quality.
The Merit Evexia Advantage
At Merit Evexia, we make CCM effortless for your practice. We handle everything—from identifying eligible patients and securing consent, to performing monthly check-ins, tracking time, documenting services, and submitting clean claims. Our turnkey solution integrates with your existing workflow and EHR system, ensuring full compliance and minimal disruption.
Our trained care coordinators serve as an extension of your team, keeping patients informed, engaged, and supported throughout their chronic care journey. Whether you’re a solo practitioner or part of a larger group, Merit Evexia can help you deliver high-quality, value-based care while boosting patient satisfaction and practice revenue.
