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CMS-Reimbursed Program

Chronic Care
Management

A fully managed CCM service for patients with two or more chronic conditions — delivered by AuriaMedical's clinical operations team so your staff can focus on in-office care.

📊 147 Active Patients
💰 $8,820 / mo
✅ 94% Contacted
CCM Patient Dashboard
Enrolled
147
↑ 12% this month
Avg Conditions
3.8
per patient
Contacted
94%
within 30 days
Revenue / mo
$8.8k
↑ 18% YTD
Hypertension68%
Diabetes54%
CKD31%

Two or more chronic conditions, significant risk

Medicare patients with two or more chronic conditions expected to last at least 12 months — or until death — that place the patient at significant risk of death, acute exacerbation, functional decline, or high resource utilization are eligible for CCM.

These patients need continuous, proactive engagement between office visits. Without a structured program, they fall through the cracks — missed medications, skipped follow-ups, uncoordinated specialist care, and preventable hospitalizations.

AuriaMedical installs a fully managed CCM operation inside your practice — clinical staff, workflows, documentation, and billing — so the revenue and the care happen without adding to your team's burden.

117M+
Americans with 2+ chronic conditions
$0
Cost to patient with Part B coverage
Patient Profile HTN Hypertension DM Diabetes CHF Heart Failure CKD Kidney COPD Pulmonary MDD Depression

Conditions covered under CCM

Patients with the following chronic conditions lasting 12+ months are typically eligible. Most Medicare patients in a primary care panel qualify.

❤️
Hypertension
High blood pressure management
🩸
Diabetes
Type 1 & Type 2 glycemic management
💓
Congestive Heart Failure
Fluid management, symptom monitoring
🫘
Chronic Kidney Disease
GFR tracking & nephrology coordination
🫁
COPD
Respiratory function & exacerbation prevention
⚖️
Obesity
BMI management & behavioral support
🫀
Coronary Artery Disease
Cardiac risk factor management
Atrial Fibrillation
Rhythm monitoring & anticoagulation support
💨
Asthma
Trigger avoidance & rescue plan reinforcement
🧠
Depression
Behavioral health & PHQ follow-up
🦴
Osteoarthritis
Pain management & mobility support
👥
Multiple Comorbidities
Complex multi-condition elderly patients with highest CCM revenue potential

Everything handled by
our clinical team

AuriaMedical acts as an extension of your practice. We own the workflow end-to-end.

📞

Monthly Patient Outreach

Structured monthly touchpoints with eligible enrolled patients — call attempts, documentation, and escalation notes all handled by our staff.

📋

Care Plan Development & Support

Comprehensive care plans for each enrolled patient, kept current with active conditions, medications, and care goals.

💊

Medication & Symptom Follow-Up

Proactive follow-up on medication adherence, side effect reporting, and symptom progression between visits.

🎯

Adherence Tracking

Patient-level tracking of care plan adherence, appointment compliance, and self-management goal progress.

🚨

Escalation Workflow

When clinical concerns arise, our team escalates to the appropriate provider with full documentation — not a voicemail.

⏱️

Time Capture & Audit Trail

Precise tracking of clinical staff time per patient per month — fully compliant with CMS billing requirements and audit-ready at all times.

🔗

Specialist & Referral Coordination

Communication with specialists, tracking of referral follow-through, and coordination of care across the patient's full care team.

💳

Billing Support

Monthly billing reports with CPT codes, patient lists, and time summaries — handed directly to your billing team or integrated with your RCM workflow.

🏥

Your Staff Does Not Carry This Program

AuriaMedical's clinical operations team handles all patient outreach, call documentation, care plan maintenance, and time capture. Your practice receives the monthly billing summary and the revenue — without adding tasks to your front desk, MA, or nursing staff.

A continuous care cycle —
every 30 days

CCM isn't a one-time touchpoint. Our team operates a recurring monthly workflow for every enrolled patient.

📋
Week 1
Enrollment & Care Plan
Patient enrolled, consent documented, comprehensive care plan created with active conditions and medications.
📞
Monthly
Outreach & Assessment
Clinical staff contact — symptom check, medication adherence, self-management, barriers to care.
📊
Ongoing
Time Capture & Documentation
All clinical staff time logged per patient, care plan updated, escalation notes filed.
🚨
As Needed
Escalation & Coordination
Urgent concerns routed to provider. Specialist coordination and referral tracking managed.
💳
Month End
Billing Report Delivered
Complete billing summary with eligible patient list, CPT codes, and time documentation sent to practice.

CCM CPT Codes &
Billing Structure

Medicare reimburses CCM on a per-patient, per-month basis. Rates shown are approximate national average Medicare allowable.

Primary
99490
Chronic Care Management — Initial 20 Minutes
Covers the first 20 minutes of clinical staff time in a calendar month for patients with two or more chronic conditions. Requires consent, a comprehensive care plan, 24/7 access to care, and documented time.
~$62 / patient / month
Add-On
99439
CCM Add-On — Each Additional 20-Minute Block
Each additional completed 20 minutes of clinical staff CCM time in the same calendar month. Can be billed twice per month (two units maximum), incentivizing deeper engagement with complex patients.
~$47 per additional 20-min block
Complex CCM
99487
Complex CCM — Initial 60 Minutes
For patients requiring complex medical decision-making. Requires 60 minutes of clinical staff time in the calendar month. Higher acuity, higher reimbursement for complex comorbid patients.
~$134 / patient / month
Complex Add-On
99489
Complex CCM Add-On — Each Additional 30 Minutes
Each additional 30-minute block for complex CCM patients. No cap on units per month for complex patients, supporting intensive care management reimbursement for high-need populations.
~$68 per additional 30-min block

Monthly billing potential
for your practice

Based on standard 99490 billing at ~$62/patient/month. Most practices see higher yields with add-on codes.

$3,100
50 patients enrolled / mo
$6,200
100 patients enrolled / mo
$12,400
200 patients enrolled / mo

Estimates based on ~$62/patient/month for 99490. Add 99439 for patients receiving 40+ minutes and complex CCM codes for high-acuity patients to substantially increase per-patient yield. AuriaMedical handles all enrollment, documentation, and billing support to maximize your eligible panel.

Ready to launch CCM
in your practice?

AuriaMedical handles everything — from patient identification to monthly billing reports. Schedule a demo to see the program in action.