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Chronic Care Management (CCM)

DHCT Chronic Care Management

Medicare's Chronic Care Management Program is designed for patients and providers to mitigate the risk of patients having emergency room visits.  Our HealthyRPM platform and our implementation model works as an extension of your practice.


CCM services require documentation of 20 minutes of non-face-to-face are per enrolled CCM patient, per calendar month in order to bill.  Care coordination can encompass a variety of activities that benefit patients with chronic conditions such as refilling prescriptions, arranging transportation, and updating medical records.  All care coordination activities must be documented in a comprehensive care plan.  Our web-based HealthyRPM patient engagement application can manage your documentation needs.  

Principal Care Management (PCM) is comprised of 30 minutes of "provider" time each calendar month to care for a patient.  Like CCM, PCM is intended to reimburse physicians and other providers such as nurse practitioners and physician assistants for the additional work they do caring for high-risk, complex patients, where the additional work is targeting one chronic care condition.  Billing code G2064 is used for reimbursement of the work associated with a targeted care plan for one chronic care condition.  Additionally, billing code G2065 accommodates the clinical staff's participation by a provider each calendar month for patient care.  Provider supervision does not require the provider to be onsite while the clinical staff performs PCM services.

Patient-Centric Dynamic Care Plan

Why is a patient-centric dynamic care plan important?  CMS implemented this program to lower costs by mitigating the risks of patients incurring emergency room visits by enhancing patient health.  Patients will NOT continue to participate in a monthly follow-up if the encounter is NOT adding value for them.  Our dynamic care plan allows format allows the clinical staff and the patient the opportunity to document and track the progress of goals, medication adherence, and symptoms in a manner relevant to the patient.

CPT Billing Codes

CCM CPT 99490

CCM CPT 99439

CCM G0506

PCM G2064

PCM G2065

Our Turnkey Model

Turnkey Model.PNG

Contact us to learn more about how DHCT can implement CCM for your practice, physician group, or ACO with little disruption to your workflow.   We will conduct a free population assessment for your practice.  Let us work with you to determine a REALISTIC opportunity for your patients and your practice.

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