Chronic Care Management: The Blueprint for Continuous, Collaborative Patient Care
Vivo Care | 28 October 2025
4 minute read
The Problem of Fragmented Care
Every month, clinicians across primary care, cardiology, nephrology, endocrinology, and behavioral health spend hours helping patients manage multiple chronic conditions. Much of this work happens between visits: reviewing data, coordinating with other providers, and ensuring adherence. Chronic Care Management (CCM) was created by CMS to close that gap and formalize continuous, non–face-to-face care between appointments.
“CCM bridges the gap between episodic and continuous care. It brings structure to what clinicians have always known – regular, proactive engagement improves outcomes and reduces hospitalizations real life.”
— Dr, Aamir Iqbal Medical Director, Vivo Care
Why CMS Created CCM
Chronic illness drives a large share of healthcare costs among older adults, much of it from preventable hospitalizations and emergency visits. To address this, the Centers for Medicare & Medicaid Services (CMS) launched Chronic Care Management (CCM) in 2015 to strengthen continuity between visits through proactive care coordination, medication management, and structured follow-up.
The goal: help practices stay connected with patients living with multiple chronic conditions while reducing avoidable acute care.
Since its introduction, CCM has demonstrated measurable impact. A CMS-commissioned evaluation by Mathematica Policy Research found that beneficiaries enrolled in CCM had lower hospitalization and emergency department use, resulting in an average $74 in monthly Medicare savings per participant, about $888 per year, driven primarily by reductions in inpatient and post-acute costs.
More recent peer-reviewed studies (Hong et al., 2024; Shao et al., 2022) continue to confirm these findings, showing that patients engaged in CCM experience fewer all-cause hospitalizations and ED visits than comparable groups not receiving coordinated chronic care support.
Sources: Mathematica Policy Research, “Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services,” CMS (2017); Hong D et al., J Gen Intern Med (2024); Shao Y et al., Medical Care (2022).
How the Program Works: Core Framework & Medicare Requirements
Eligibility — Two or more chronic conditions expected to last ≥12 months (or until death) with meaningful risk of exacerbation or functional decline.
Care Plan — A comprehensive, electronic plan that’s shared with the patient and all treating providers.
Patient Consent — Documented prior to enrollment; patients can opt out any time.
Access & Documentation — 24/7 care coordination access; track monthly time against CCM codes (99490, 99439, 99491, 99487, 99489).
Pro tip: Modern chronic care management software streamlines documentation, time logs, and audits so staff can focus on patient care.
Program Evolution: Timeline at a Glance
2015: CCM Launch (99490) – First payment for ≥20 minutes of non–face-to-face clinical staff time.
Patient disengagement: Track outcomes (BP, A1c, symptoms) and celebrate wins to improve retention.
CCM Codes (Quick Reference)
99490: Foundational CCM ≥20 min (staff). +99439: Each additional 20 min (staff). 99491: Practitioner-only ≥30 min (clinician). +99437: Each additional 30 min (clinician). 99487: Complex CCM ≥60 min (staff). +99489: Each additional 30 min.
If you want a consultation on your current CCM program or are considering starting one, click here to schedule a free consultation with one of our team members, or call 888-440-VIVO.
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