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Chronic Care Management

Network Overview

The Centers for Medicare & Medicaid Services (CMS) has introduced a series of simple payment codes for chronic care management (CCM) services including non face-to-face care for routine and complex CCM services. CCM services are provided to Medicare beneficiaries with two or more chronic conditions that are expected to last at least 12 months or until death. One CCM payment code enables eligible clinicians to receive reimbursement when providing Medicare beneficiaries with 20 minutes of routine, non-face-to-face, care coordination services, while the payment codes for complex CCM services have additional requirements and offer various levels of reimbursement.

Join the Chronic Care Management Network

According to CMS, only 100,000 Medicare beneficiaries are receiving these valuable CCM services, despite 35 million being eligible for it, based on billing records as of October 2015. To help increase the number of practitioners effectively implementing and providing CCM services to their patients, the TMF Quality Innovation Network Quality Improvement Organization (QIN-QIO), will provide technical assistance and support to physicians, nurse practitioners and physician assistants in Arkansas, Missouri, Oklahoma and Texas.

Our consultants will work with clinicians to identify eligible patients and to coordinate CCM with processes such as billing, documentation and service tracking tools. The TMF QIN-QIO will also provide educational tools, resources and events to support your CCM efforts.

Download this fact sheet to learn more about the Chronic Care Management network. To join, create a free account and follow the prompts.



Quick Links

Download these resources to learn more about the Chronic Care Management (CCM) network and the business case for joining.

Physicians and clinicians: Please review the Business Case, below, to learn the benefits of offering CCM and joining the CCM network.

Physicians and clinicians may download the Revenue Calculator, below, and use it to estimate revenue. You may input hourly rates, hours per patient or number of patients per year, which will result in automatic calculation of revenue.

Physicians and clinicians may download the CCM Process Checklist, below, to guide them through the process as well as keep track of action items. It also includes links to useful tools for completing specific process action items.

View resources for patients and families.

Contact Information

Chronic Care Management

May 10-11 Symposium

2018 Novitas Solutions Medicare Symposium

Register today for the first symposium with Novitas Solutions in Albuquerque, New Mexico, May 10 and 11, 2018, to learn more about current information regarding Medicare. Visit this webpage for a schedule and short descriptions on each of the presentations, and for some quick tips on registration, contact information and more.

May 22 Webinar

Implementing Chronic Care Management through Population Health Programs

Register today for this TMF Quality Innovation Network webinar on Tuesday, May 22, from noon to 1 p.m. CT. Speaker Pam Audish, RN, BSN, CCM, VP of Medical Management at Innovista Health Solutions, will discuss using registries to identify complex patients and patients who would benefit from condition management (such as diabetes, congestive heart failure and chronic obstructive pulmonary disease). Using these programs to implement population health will help practices provide chronic care management through evidence-based management programs.

Texas • Arkansas • Missouri • Oklahoma • Puerto Rico