Chronic Care Management Documentation: Best Practices

Chronic diseases require ongoing care, coordination, and patient engagement—yet many healthcare providers struggle to dedicate the necessary time and resources. Chronic Care Management (CCM) bridges this gap, ensuring that patients receive continuous support while providers are properly reimbursed for their efforts. Medicare’s CCM program allows healthcare organizations to bill for non-face-to-face care coordination services provided to patients with chronic conditions. However, to receive reimbursement, practices must meet strict chronic care management documentation and billing requirements. This guide outlines best practices to ensure compliance and maximize efficiency.

Chronic Care Management Documentation Requirements

To bill for CCM services, providers must maintain detailed documentation that includes:

1. Patient Consent – Before initiating CCM, the patient must provide verbal or written consent, which should be documented in the electronic health record (EHR). Consent must include:
   • An explanation of CCM services and the patient’s eligibility.
   • Cost-sharing details, including co-pays and deductibles.
   • Acknowledgment that only one provider can bill for CCM per month.
   • The patient’s right to discontinue CCM services at any time (effective at the end of the calendar month).
2. Care Plan and Diagnosis Documentation
   • Patients must have two or more chronic conditions expected to last at least 12 months or until death.
   • The patient-centered care plan should include:
     • Health concerns, goals, and interventions
     • Medication reconciliation and management
     • Planned follow-ups and care coordination details
3. Time-Based Service Tracking
   • Clinical staff must spend at least 20 minutes per month on non-face-to-face CCM activities, such as:
     • Coordinating care between providers
     • Medication management and prescription reviews
     • Proactive patient outreach (phone calls, remote monitoring follow-ups)
   • Accurate time tracking is essential—document total time spent, the provider’s name, and the services provided.
   • Medicare requires exact minute tracking, not rounded estimates.

CCM Billing Codes and Reimbursement

CMS provides multiple CPT codes for CCM, depending on complexity and time spent.

Key Billing Considerations

• CCM can be billed once per month, per patient.
• Extended CCM services (additional time beyond 20 minutes) must be billed using add-on codes.
• Dates of service must align with the calendar month when submitting claims.

Best Practices for CCM Success

1. Simplify Patient Enrollment
   • Introduce CCM during office visits and explain the benefits in plain language.
   • Provide a take-home overview of CCM services, including the 24/7 care coordination number.
   • Digitize consent forms for easy documentation in the EHR.
2. Streamline Documentation with Technology
   • Use EHR-integrated CCM modules to track service time.
   • Automate reminders for outreach and follow-ups to ensure minimum time thresholds are met.
3. Combine CCM with Remote Patient Monitoring (RPM)
   • Many patients in CCM programs benefit from RPM for conditions like hypertension, diabetes, and heart disease.
   • Billing for both CCM and RPM can increase reimbursements while improving patient outcomes.
4. Maintain Compliance and Audit Readiness
   • Medicare audits CCM billing regularly—ensure all documentation is clear, accurate, and complete.
   • Train staff on Medicare’s latest CCM requirements to prevent claim denials.
   • Review CMS updates frequently to stay ahead of policy and reimbursement changes.

Enhancing Patient Care with CCM

CCM is a win-win for patients and providers—patients receive ongoing care and support, while practices gain revenue for essential services they may already be providing. By implementing structured workflows, leveraging technology, and staying compliant with CMS guidelines, providers can enhance care quality, patient engagement, and practice efficiency.

Seamless Chronic Care Management Documentation With BlueFish

Other CCM vendors capture encounter documentation in their own proprietary apps, and then send that information to the practice to be imported into the EHR. BlueFish is committed to making the CCM process seamless for our clients, and we ALWAYS complete encounter documentation in your practice’s EHR. BlueFish provides the highest level of CCM services, supporting your patients and practice team with:

• The ability to provide end-to-end CCM services with appropriately licensed staff, including patient sign-up, care plan creation, care provided by nursing staff, and billing
• The ability to provide your patients with 24/7 access to and continuity of care
• The ability to seamlessly extend your care team, with a service tailored to meet the needs of your patients and clinical staff without disrupting your workflows.
• The ability to easily access any care given with all documentation being completed within the provider’s EHR.

If you’re looking for someone to partner with for CCM services, BlueFish can help you build a successful chronic care management program.

To request more information about how partnering with BlueFish Medical can help you build a successful CCM program, please fill out the form below.

Editor’s Note: Updated February 2025