Start with questions, not software
Most guidance on how to start a CCM program opens with a platform or a staffing vendor. Those choices come later. Chronic care management is a monthly routine, and programs fail on routine: consent that was never documented, care plans that went stale, time nobody recorded.
Settle the questions below first. Medicare’s rules are described in general terms. Requirements differ for other payers and change over time, so the practice confirms current rules before billing.
Who on your panel qualifies, and who decides?
In general, Medicare describes CCM as a service for patients with two or more chronic conditions, expected to last at least 12 months or until the end of life, that place the patient at significant risk of decline or acute worsening. The clinician decides who fits.
Before launch, ask:
- How many patients qualify, clinician by clinician?
- Which of them have been seen recently enough to enroll without a new visit?
- Which patients would benefit from monthly contact, not merely qualify?
Enrolling everyone who qualifies on paper tends to produce a list of patients who do not answer the phone.
How will consent and cost be handled?
Patients must agree to the service before it starts, and the agreement must be documented. The conversation generally covers what the service is, that cost sharing may apply, that only one practitioner can bill it in a given month and that the patient can stop at any time. Patients who are new to the practice, or who have not been seen in some time, generally need an initiating visit first.
Cost sharing is where programs lose patients. Under Medicare, the usual deductible and coinsurance generally apply, and a patient who did not expect a monthly charge may withdraw after the first statement. Give staff a short, honest script, and do not call the service free unless you have confirmed that for the patient’s coverage.
Decide who has the conversation, where consent is recorded and what the patient takes home. Our patient guide on what to know about chronic care management can serve as the handout.
Who does the monthly work, and when?
CCM billing is tied to documented time in a calendar month, with thresholds that depend on the code. Much of that time can come from clinical staff working under the billing practitioner’s direction, subject to supervision rules the practice confirms.
Answer these:
- Who makes the contacts, who covers absences and how many patients can one person carry alongside other duties?
- When in the week does the work happen? “When things are slow” is not an answer.
- How does a symptom report or medication question reach a clinician promptly?
- Who reviews the month-end list and decides what is billed?
Can your record system carry it?
CCM requires more than phone calls. In general terms, that includes a comprehensive care plan shared with the patient, a way for patients to reach the care team about urgent needs at any hour, continuity with a designated care team member and management of care transitions.
Check whether your system can:
- Hold a structured care plan and show when it was last reviewed
- Record time as it is spent: date, staff member, activity and minutes
- Make the care plan available to whoever covers after hours
If time has to be rebuilt from memory at month end, fix that before you enroll anyone.
What else is the patient enrolled in?
Care management services overlap. A patient may also be a candidate for principal care management, transitional care management after a hospital stay or remote patient monitoring. Some combinations can be billed in the same month and some cannot, and time counted for one service cannot be counted again for another. Ask new enrollees whether another practice already provides CCM.
Practices that want a monthly model not built on counting minutes should compare CCM with advanced primary care management. If monitoring devices are part of the plan, see our RPM program startup questions.
How will you know it is working?
Pick measures before launch: patients enrolled and active, months that met the time threshold, contacts completed against planned, clinical questions escalated and closed, and patients who withdrew and why.
Then pilot with one clinician’s panel and a group one staff member can manage. Run several monthly cycles and review the measures before widening.
Gateway offers chronic care management program support for practices in Greater St. Louis and the Metro East. Eligibility, supervision and billing decisions remain with the practice. Reach us through the practice support inquiry form or at 314-325-0126.
Common questions
How many patients do we need before a CCM program makes sense?
There is no threshold. The better question is whether someone has protected hours for the monthly work. A small program run consistently is worth more than a large one with gaps in consent and time records. Enroll what your staffing can carry, then decide whether to grow.
Do we need special software to start CCM?
Not necessarily. You need a place for the care plan, a time log filled in as the work happens and one list showing each patient’s enrollment status. Many record systems can do that. Choose after a pilot, when you know what your staff needs.
Should the monthly contacts be handled in house or by an outside team?
In-house staff know the patients. An outside team brings dedicated hours and a set routine. Either way, confirm that the arrangement meets the supervision and documentation rules for the codes you bill and that clinical questions reach your clinicians. Responsibility for the claim does not transfer.
What is the most common mistake in the first few months?
Enrolling faster than the routine can absorb. Consent gets rushed, care plans are copied forward without review and time is logged late. All three surface later as months that cannot be billed with confidence. Enroll in small groups and check each patient’s records at month end.
Related pages
Updated October 2026