Chronic Care Management (CCM) is the coordinated, ongoing management of patients with chronic conditions — such as COPD, diabetes, or hypertension — typically delivered between visits and often reimbursed under specific Medicare codes.
CCM is closely related to remote patient monitoring, and adopters can be identified through diagnosis and claims patterns tied to chronic populations.
CCM, like RPM, links clinical value to recurring reimbursement, making it an attractive program for both providers and the vendors that enable it. The targeting question is which physicians manage enough chronic patients to sustain a CCM program — answerable through diagnosis and claims data.
For digital health companies, identifying practices with large COPD, diabetic, or hypertensive populations focuses outreach on the providers where a CCM offering will deliver the most value.
Chronic care management (CCM) is the coordinated, ongoing care of patients with multiple chronic conditions, delivered largely between office visits and often reimbursed by Medicare. It improves outcomes for conditions like diabetes, COPD, and hypertension through continuous management.
CCM is the coordinated management of chronic conditions, often via care coordination and check-ins, while RPM specifically uses connected devices to monitor physiologic data remotely. They're related and sometimes combined, but RPM is device-driven and CCM is care-coordination-driven.
CCM is adopted mainly by primary care physicians, pulmonologists, nephrologists, and others managing large chronic populations. Diagnosis and claims data identify which practices have the chronic-patient volume to support a CCM program.
CCM is reimbursed through specific Medicare codes covering non-face-to-face care coordination time for patients with multiple chronic conditions. This recurring reimbursement is central to the business case for CCM programs.