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Chronic Care Management Program Implementation: 5 mistakes to avoid

Chronic Care Management Program - Chronic Disease Management Program - Hifinite

Opting for Chronic Care Management (CCM) can help providers support their patients with chronic diseases during doctor's office visits. Furthermore, providers can get reimbursed for offering CCM services by the Centers for Medicare & Medicaid Services (CMS). Isn't it a win-win situation for both providers and patients? However, providers should prepare to take full advantage of CCM programs.

Sometimes, providers don't because they end up struggling with staffing, documentation, requirements, patient engagement, etc. 

Hence, this article lists those mistakes practices make while running the chronic care management program. Before that, let us go through the recent 2022 chronic care management CPT codes issued by the CMS.

2022 Chronic care management CPT codes 

Chronic care management (CCM) codes apply to patients with more than one serious chronic condition like diabetes, hypertension, asthma, COPD, chronic kidney disease, etc.

































Reasons for Chronic Care Management Program to Fail

1. Inadequate staff size


Usually, practices do not maintain adequate staff members to run the chronic care management program. It will ultimately overburden the available professionals, leading to a poorer quality of care delivery.

So, make sure to employ care managers who can be care practitioners, certified medical assistants (CMA), licensed practical nurses (LPN), and registered nurses (RN). They should spend a minimum of 20 minutes per month with every patient to use the CCM program.

Depending on your practice level, you can appoint them to a full-time or part-time position. If you cannot manage these staffing requirements, think about outsourcing service providers like Hifinite Health, who can work as an extension of your practice and get you reimbursed without any hassle.

2. Improper assessment of qualifying patients

The CMS defines qualifying patients as “people with multiple chronic diseases expected to last for a minimum of 12 months or until the patient's death. This condition also places the qualifying patients at significant risk of acute exacerbation/decompensation, functional decline, or death.

Statistics reported that nearly 76.9 percent of Medicare and Medicaid patients aged 65 and above have more than one chronic disease. Still, several practices don't get sufficient Medicare patients and find their enrollment misaligned with CCM scope. So, make sure to assess the number of Medicare-qualified patients you treat. You can check that using an electronic health record (EHR). By checking the diagnoses, you can find CCM-qualified patients and encourage them to enroll in Chronic Care Management program.

CCM program requirements

In addition to having adequate patients and staff, every practice should meet the below-listed CCM requirements, such as:

  • Certified EHR

  • 24/7 access to care member

  • Personalized comprehensive care plan

  • Signed patient consent

  • Management of care transition

  • Non-face-to-face communication between patients and the care team

  • 20-60 minutes of clinical staff time per patient per calendar month for remote engagement directed by a physician or other qualified healthcare professionals


You should fully understand the above-listed requirements to improve documentation, ease the billing process, and enhance the CCM program efficiency.

That's where implementing CCM solutions like hiCare Chronic Disease Management Solution can track your monthly encounters, manage care plans, and store electronic patient consent to streamline billing for CMS reimbursements. 

3. Documentation issues

Improper adoption or non-adoption of CCM programs can affect documentation that many practices are unaware of. Not only for personalized care delivery and revenue improvement, but the CCM program also puts documentation in place to reduce errors and increase efficiency by helping staff take up clinical tasks. Furthermore, automated documentation ensures accuracy and proper reimbursement during audits without hassle. A chronic care management solution can either help you with a certified EHR or bolt into an existing one to streamline the entire CCM billing process while ensuring secure storage in the cloud. So, take sufficient time to assess your documentation practices so that they can support your CCM program.

4. Inefficient patient churning


Due to inefficient health records management, practices usually miss out on streamlining their CCM-qualified Medicare patients. In such cases, having a CCM program with certified EHR can manage this patient churn by classifying chronically-ill patients from the group. By doing so, it is possible to encourage and enroll new patients while ensuring high patient satisfaction rates.

4. Lack of proper support

Improper training, misconceptions about the CCM program, and lack of knowledge keep the providers at bay. That's where you need the help of an experienced chronic care management solution provider who can offer timely support to ensure the success of the CCM program while boosting the revenue for doctors.

Final Thoughts


Adopting a user-friendly chronic care management program is essential for every healthcare organization. As many care providers have already started implementing a CCM solution, what are you waiting for? Invest in the CCM solution right away. If you have difficulty managing the entire CCM program, partner with experienced chronic care management solution providers like Hifinite Health to ensure nothing slips through the cracks. Schedule a free demo to know how it can help increase your practice revenue while improving the health outcomes of your chronically-ill patients.

CPT Code
Time (min)
Monthly Reimbursement per patient
Key Points
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