Definition
Chronic Care Management (CCM) is a Medicare-reimbursed service in which a care team provides ongoing, non-face-to-face care coordination each month for patients with two or more chronic conditions expected to last at least 12 months.
CMS began paying separately for CCM in 2015. Billing requires the patient's consent, a comprehensive care plan, and a minimum amount of clinical staff time per calendar month, with additional codes for more time or more complex care. In 2025 CMS added Advanced Primary Care Management (APCM) codes that bundle similar care-management elements into a monthly payment for practices meeting primary-care requirements.
Both programs depend on recurring patient contact: monthly check-ins, medication and symptom review, chasing missing information, and coordination between visits. That recurring outreach is labor-intensive, which is a common reason eligible patients are under-enrolled or under-served.
How Consig handles it
Consig runs the recurring outreach that CCM and APCM programs depend on; a CCM demo that chases missing device readings is listed on the Solutions page as coming soon.