CCM (Chronic Care Management)
Four programmes, one enrollment workflow
Since 2015 CMS has paid separately for care management furnished between visits, and the list of programmes has grown since. NovoClinical supports four of them — CCM (Chronic Care Management), RPM (Remote Patient Monitoring), RTM (Remote Therapeutic Monitoring) and BHI (Behavioral Health Integration) — through the same enrollment, tracking and billing workflow, so your team learns one process rather than four.
Administered well, these programmes improve outcomes for patients who would otherwise only be seen when something goes wrong, and they add a recurring revenue line to the practice. Administered badly, they lose money. The difference is almost always the same thing: whether the time spent on each patient is actually being captured.
Where most programmes fail
Care management is billed on time. A nurse spends eleven minutes on a phone call, a care coordinator reviews readings for six,
Where most programmes fail
Care management is billed on time. A nurse spends eleven minutes on a phone call, a care coordinator reviews readings for six, someone updates the care plan for four — and unless every one of those minutes is recorded against the right patient in the right month, the claim either cannot be justified or is never made at all. Practices that run these programmes on spreadsheets and memory are the ones that report them as financial failures.
In NovoClinical the time is logged where the work happens. Every interaction is recorded against the patient with the minutes attached, so at month end you can see who has crossed the billing threshold and who is short — while there is still time to make the call that gets them there.
How it works
- Enrollment — eligible patients are enrolled per programme, with consent captured and recorded for that programme.
- Care plans — goals and interventions documented, reviewed and signed by the provider.
- Interactions and time — every contact logged with the time spent, and interactions flagged where they need provider review.
- Device readings, for RPM — blood pressure, blood glucose, weight, oxygen saturation and other readings flow in from connected devices into the patient’s chart, with staff review time logged against them.
- Monthly claims — once a patient meets the time threshold, the monthly claim is generated from the tracked time rather than reconstructed by hand.
Who sees what
Care managers and coordinators enroll patients and record interactions. Nurses and medical assistants document contacts and update goals. Providers review and sign care plans and approve the interactions that need them. Billing staff generate the monthly claims once thresholds are met. Administrators watch enrollment counts and programme revenue on the care management dashboard.
Because all of this runs inside the same system as the chart and the billing, the claim traces back to the documented time, and the documented time traces back to the patient’s record.