Chronic Care Management: The Blueprint for Continuous, Collaborative Patient Care
Vivo Care | 28 October 2025
4 minute read
The Problem of Fragmented Care
“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
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).
Program Evolution: Timeline at a Glance
2015: CCM Launch (99490) – First payment for ≥20 minutes of non–face-to-face clinical staff time.
