Coordinated care,
month after month.
For patients with two or more chronic conditions: care plans, medication management, and steady human contact — with documentation built in.
The mechanics of good chronic care.
CCM works when the plan is real, the contact is consistent, and the documentation is clean. We handle the operational layer so your team can focus on the clinical one.
Personalized care plans
Care plans built around each patient’s conditions, goals, and barriers — updated as their picture changes.
Medication management
Reconciliation, adherence tracking, and side-effect monitoring across the full medication list.
Care team coordination
A shared workspace that connects providers, care managers, patients, and caregivers around one plan.
Progress tracking
Outcomes captured over time, with the reports your team needs for quality programs and audits.
From enrollment to reimbursement.
Identify eligible patients
Patients with two or more chronic conditions are surfaced from your panel for enrollment review.
Build the care plan
A comprehensive plan is built with the patient — covering medications, goals, and check-in cadence.
Coordinate the month
Our care managers log time on calls, education, coordination, and medication checks across the month.
Bill & report
Time and activities map to 99490, 99439, and complex CCM codes — handled by our billing team.
Everything a CCM month actually requires.
CMS rules are specific. We build the program around the rules, not the other way around.
Comprehensive care plan
Built and maintained for each enrolled patient.
20+ min of care manager time
Each calendar month, logged and audit-ready.
Medication reconciliation
Each plan visit and care-plan refresh.
Compliance documentation
Time logs, consent, and reporting kept in order.
Healthier panels, steadier practices.
CCM is one of the most reliable ways to improve outcomes on your sickest patients — and it adds a durable monthly revenue stream while doing it.
- Better outcomes on multi-condition patients
- Reduced ED visits and readmissions
- Higher patient satisfaction and trust
- More face-time saved for in-person visits
- Sustainable monthly revenue stream
- Streamlined care team coordination
The billable CCM building blocks
99490
20+ min care manager time
99439
Each additional 20 min
99487
Complex CCM, 60 min
99489
Complex CCM, +30 min
Take the operational layer off your plate.
A short scoping call is the fastest way to see how CCM fits your panel.