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Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acu

CPT4 code

Name of the Procedure:

Chronic Care Management Services (CCM)


Chronic Care Management Services (CCM) provide comprehensive care coordination and management for patients with two or more chronic conditions expected to last at least 12 months, or until the death of the patient.


Chronic care management services are designed to address multiple chronic medical conditions that place the patient at significant risk of death, acute exacerbation, decompensation, or functional decline. The goals include better management of chronic diseases, reduction in hospital admissions, improved quality of life, and enhanced patient satisfaction.


  • Patients with two or more chronic conditions such as diabetes, heart failure, chronic obstructive pulmonary disease (COPD), hypertension, or arthritis.
  • Patients who frequently experience complications or exacerbations of their chronic conditions.
  • Patients requiring regular monitoring, management, and coordinated care across multiple healthcare providers.


  • No specific pre-procedure instructions are typically necessary.
  • A comprehensive initial assessment is performed to determine the patient's medical needs and to develop a personalized care plan.
  • Coordination of care with all healthcare providers involved.

Procedure Description

  1. Initial Assessment: A thorough review of the patient's medical history, current conditions, medications, and lifestyle.
  2. Care Plan Development: Creation of a personalized, patient-centered care plan that outlines management strategies, goals, and interventions.
  3. Regular Monitoring: Scheduled check-ins, either in-person or remotely, to track the patient's progress and adjust the care plan as needed.
  4. Care Coordination: Collaboration with healthcare providers, specialists, and community resources to ensure integrated and cohesive care.
  5. Patient Education: Providing the patient and their caregivers with information and support to manage chronic conditions effectively.


CCM is an ongoing service, with regular interactions monthly, and typically requires at least 20 minutes of clinical staff time each month.


CCM services can be provided in a variety of settings, including primary care offices, outpatient clinics, or remotely via telehealth.


  • Primary care physicians
  • Nurse coordinators
  • Medical assistants
  • Case managers
  • Other allied health professionals as needed

Risks and Complications

  • There are minimal direct risks associated with CCM.
  • Potential risks might include information overload for patients and challenges in medication adherence.


  • Improved management of chronic conditions.
  • Reduction in hospital readmissions and emergency department visits.
  • Enhanced quality of life for patients.
  • Better alignment of care among various healthcare providers.


  • There is no recovery phase as CCM is a continuous management approach.
  • Patients may see improvements in their conditions and overall health status over time.
  • Regular follow-up appointments ensure ongoing assessment and modification of the care plan.


  • Traditional care management without a formally structured program.
  • Home health care services.
  • Self-management with guidance from primary care physicians.
  • Each alternative has its benefits and limitations in terms of comprehensiveness, cost, and patient engagement.

Patient Experience

  • Patients generally experience increased communication and support from their healthcare team.
  • They may notice an improvement in understanding their conditions and how to manage them effectively.
  • Regular check-ins and proactive management help in reducing stress and improving overall well-being.
  • Careful attention to comfort measures and effective pain management strategies are integrated into the care plan where necessary.

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