Chronic Care Management (CCM) is an essential aspect of healthcare that involves providing non-face-to-face services to patients with two or more chronic conditions. These visits typically occur between office visits, and take place virtually with the patient remaining at home. According to the World Health Organization (WHO), chronic diseases are responsible for 71% of all deaths worldwide, and the burden of chronic diseases is increasing rapidly.

The WHO estimates that around 41 million people die globally each year from chronic diseases such as heart disease, cancer, diabetes, and chronic respiratory diseases. In addition, many people suffer from the debilitating long-term effects of chronic conditions, significantly reducing their quality of life and ability to function.

Remote Patient Monitoring (RPM) is a complementary technology gaining traction in healthcare that involves using connected devices to collect and transmit health data from patients to healthcare providers. In this post, we examine the benefits of adding RPM to CCM and how this can improve patient outcomes.

Key takeaways:

  • Chronic care management (CCM) is an increasingly necessary—but challenging—aspect of healthcare, leading to high costs, medical staff burnout, and underserved patients.
  • Remote patient management (RPM) helps lower CCM’s labor and material costs, improve patient outcomes, and restore provider morale.
  • Using RPM enables healthcare professionals to increase practice revenue while delivering enhanced care for CCM patients through proactive oversight and better outcomes.

The Challenge of Chronic Care Management

Chronic care management allows healthcare providers to supervise the treatment of these conditions in patients who require ongoing care. The program provides services such as care coordination, medication management, and patient education with a view to improving healthcare outcomes. Centers for Disease Control (CDC) reports show that 90% of America’s $1.4 trillion annual healthcare spending goes on managing chronic diseases and mental health.

Types of CCM Programs

Healthcare uses several types of CCM programs currently, and providers can choose the program that best suits the needs of their patients. These include:


Medicare reimbursement rates for CCM, which are as follows:

  • 99490 (20 minutes of time) – $62.69
  • 99439 (additional 20 minutes) – $47.44
  • G0511 (20 minutes by RHC/FQHC) – $76 (This is the general care management code when billing for CCM services in FQHCs/RHCs).

Complex CCM

Reimbursements for this program are:

  • 99487 – Complex CCM (60 minutes) – $133
  • 99489 – Complex CCM (additional 30 minutes) – $70

CCM is typically provided by clinical staff under the supervision of a practitioner and is covered by Medicare and some private insurance plans. Studies have shown that the benefits of CCM, such as reduced hospitalizations and emergency room visits, significantly outweigh the costs of the program. Studies show patients who receive more CCM time have lower hospital admission rates and emergency department visits.

Read: CMS – Chronic Care Management and Connected Care

Integrating RPM into CCM

RPM is a perfect add-on to CCM because it serves the same population of patients, allowing healthcare providers to monitor them remotely and in real time. Patients with chronic conditions get ongoing oversight, and RPM provides an opportunity to collect health data outside the clinical setting. RPM also allows for early intervention and personalized care, which can improve patient outcomes.

RPM can be integrated with CCM through various methods, including connected devices, patient portals, and mobile apps. These opportunities give healthcare providers a more comprehensive view of their patients’ health, which can inform care decisions and improve patient outcomes.

Benefits of using RPM for CCM

RPM supplements CCM programs by providing real-time biometric data to care providers, enabling them to monitor patients’ health status more frequently and intervene earlier if necessary. This delivers valuable benefits for practitioners, including:

  • More Frequent Monitoring: CCM typically involves monthly check-ins with patients to review their care plans. With RPM, practitioners depend less on the patient trying to remember the symptoms experienced during the previous month. RPM enables them to see patient vitals and how the care plan is affecting biometrics. For example, one of the goals for someone with hypertension may be to achieve their target BP. With RPM, the provider can see the trends collected over time from health monitoring devices like blood pressure monitors or glucose meters and determine whether or not the patient reaches the goal. RPM can supplement this by providing more frequent patient health status monitoring, such as daily or weekly data collection.
  • Early Intervention: With more frequent monitoring, providers can identify patient health changes earlier and intervene before the condition worsens. For example, RPM can detect a rise in blood glucose levels with 98.7% sensitivity and 99.3% specificity, alerting the healthcare provider who can then adjust the patient’s medication or treatment plan.
  • Personalized Care: RPM can also supplement CCM by providing healthcare providers with a more comprehensive view of their patients’ health, enabling them to provide more personalized care based on individual needs.

Read: McKinsey & Company – The role of personalization in the care journey. An example of patient engagement to reduce readmissions

  • Improved Patient Engagement: RPM supports CCM by enabling patients to participate more actively in their own care. By providing patients with real-time health data, they can be more engaged in managing their condition and be more likely to follow their treatment plan.
  • Reduced Healthcare Costs: By supplementing CCM with RPM, healthcare providers can reduce healthcare costs by reducing hospitalizations and readmissions, emergency department visits, and other costly interventions. Early intervention and personalized care can also improve patient outcomes, leading to fewer complications and reduced healthcare costs over time.
  • Increased Revenue: Practices can bill both RPM and CCM for the same patient each month because CMS recognizes the two services as complementary. However, only one doctor per patient can bill for RPM and CCM each month.

As the healthcare industry continues shifting toward value-based care, RPM will continue to be an important tool for managing chronic conditions and improving patient outcomes.

Embracing Remote Patient Monitoring Delivers Better Chronic Care Management

Adding RPM to CCM can significantly benefit patients with chronic conditions and their healthcare providers. RPM allows for consistent oversight, personalized care, and early intervention, which can further improve patient outcomes and reduce healthcare costs. As technology advances, embracing new tools and techniques will also allow providers to guarantee better medical data management for their patients.

For more information about RemetricHealth’s remote patient monitoring and how to integrate it with your CCM program, please contact us to discuss your needs and arrange a demonstration.