Chronic Care Management
Consistent Care. Real Relief.
CCM keeps your practice connected to patients with ongoing conditions through consistent, structured monthly check-ins. We handle enrollment, coordination, and reporting so your team stays focused on in-person care. Your patients get reliable support between visits, and your practice gains steady, recurring revenue without extra workload.
Extend Care Between Visits
Chronic care management keeps patients supported between visits through steady check-ins, clear communication, and ongoing guidance to help them stay on track.
Keeps patients supported every day.
Hassle-Free Enrollments
We make it easy for your clinic to bring patients into the program without extra admin work, keeping the process quick, clear, and consistent for every new enrollee.
Makes onboarding smooth for everyone.
Continuous Care & Support
Your clinic gets continuous help with patient check-ins, device questions, and billing and reimbursement, so your staff can stay focused on care—not admin tasks.
Gives your team help when they need it.
How Chronic Care Management (CCM) Works
Chronic Care Management supports patients with two or more chronic conditions through structured monthly check-ins and ongoing coordination. A dedicated care team documents time spent, communicates with patients between visits, and keeps providers updated on any changes in their health needs.
This steady touchpoint helps patients stay on track while reducing avoidable hospitalizations. Practices gain predictable monthly revenue without adding strain to in-office staff or disrupting existing workflows.
This steady touchpoint helps patients stay on track while reducing avoidable hospitalizations. Practices gain predictable monthly revenue without adding strain to in-office staff or disrupting existing workflows.
Monthly outreach keeps patients supported between visits.
Care teams review needs, medications, and goals.
Time spent is logged and tracked for accurate billing.
Providers receive updates when patient needs change.
Patients stay engaged without extra office appointments.
Care Activities included with CCM
- Monthly patient check-ins
- Medication review and reconciliation
- Care plan updates
- Coordination with specialists
- Tracking symptoms and goals
- Ensuring patients follow their treatment plan
Why It Matters
- Keeps chronic patients engaged between visits
- Reduces avoidable ER and hospital use
- Visibility into patient needs
- Builds predictable, recurring revenue for your practice
Real Benefits For Your Practice and Your Patients
CCM gives practices a structured way to stay connected with patients who need ongoing support. Instead of relying solely on office visits, your care team can guide patients monthly, adjust care plans, and address small issues before they grow. It strengthens continuity, improves how patients manage their conditions, and creates a steady revenue stream without changing how your clinic already operates.
Monthly touchpoints help patients stay on track with medications and care plans.
Clearer visibility into patient challenges reduces avoidable complications.
Consistent documentation and time tracking create dependable reimbursement.
Care coordination improves outcomes without adding extra strain to your staff.
What Your Team Gains
- Reliable Monthly Revenue
- Better insight into patient stability between visits
- Less admin work
- Fewer unexpected escalations
What Your Patients Gain
- More frequent touchpoints with clinical staff
- Earlier detection of changes in their condition
- A sense of connection and reassurance between appointments
Why Partner with NXT?
Partnering with NXT gives your practice access to a fully managed CCM program supported by multiple trusted vendors. Our team coordinates device logistics, onboarding, monitoring, and monthly documentation so your staff doesn’t take on extra work.
You get a single, streamlined solution without managing technology, training, or compliance on your own. This setup keeps the process simple for your practice while giving patients consistent support and reliable follow-up.
You get a single, streamlined solution without managing technology, training, or compliance on your own. This setup keeps the process simple for your practice while giving patients consistent support and reliable follow-up.
Individual eligibility verification completed before enrollment.
Hands-free device ordering, shipping, activation, and replacement.
Comprehensive patient onboarding and ongoing support.
Daily monitoring and clinical review
Documentation and billing support to keep the program compliant.
What We Handle
- Eligibility checks
- Device logistics
- Onboarding and support
- Daily monitoring and documentation
- Monthly Billing
What You Avoid
- Device Management
- Extra Workload on Staff
- Compliance Risk
- Internal CCM Workflows
How Our Process Works
Our remote care solutions are designed to integrate effortlessly into your existing workflow. We connect your patients to continuous monitoring and ongoing support—without disrupting your day-to-day operations. From onboarding and device setup to data review and compliance reporting, our team manages every step so your staff can focus on what matters most: quality care and patient relationships.
FAQ
Frequently Asked Questions
Commonly asked questions regarding Chronic Care Management (CCM)
Contact UsWhat is Chronic Care Management?
Chronic Care Management is a Medicare program that supports patients with multiple chronic conditions through ongoing, non-face-to-face care coordination. It helps keep patients stable between visits while improving outcomes and practice efficiency.
What are the chronic care management CPT Codes?
The main CCM codes include 99490, 99439, 99491, and 99437, each tied to different time requirements and whether services are delivered by clinical staff or a provider. These codes outline how practices are reimbursed for monthly care management.
What conditions qualify for chronic care management?
Patients must have at least two chronic conditions expected to last 12 months or more, or until death. These conditions must also place them at significant risk of decline, exacerbation, hospitalization, or death. Conditions such as diabetes, hypertension, COPD, Congestive heart failure, chronic kidney disease, alzheimer's or other dementias, arthritis, and depression are a few common examples of conditions that would fall under these categories.
What is the difference between chronic care management and remote patient monitoring?
CCM focuses on care coordination, communication, and patient management done outside of face-to-face visits. RPM uses connected devices to gather physiological data, giving providers real-time insight into a patient’s health.
Can my practice do RPM and CCM?
Yes, practices can run both programs together as they complement each other and serve different parts of patient care. Many clinics use both to improve outcomes and earn additional recurring revenue.
Is NXT a chronic care management company?
NXT partners with leading CCM vendors to deliver a complete, turnkey solution for practices. We handle program setup, workflow support, and coordination so clinics can offer CCM without adding internal workload.
Do I need chronic care management certification or training?
Providers don’t need a special certification, but they do need a compliant workflow that meets Medicare requirements. NXT and our partners guide practices through setup, training, and ongoing best practices.
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Let’s talk about your next milestone—and how to reach it
Alex Tran
Founder & CEO
