Most practices already have qualifying CCM patients in their panel — the challenge is usually identifying them systematically rather than case by case. Here's what to look for.
The General Qualifying Criteria
Patients generally qualify for CCM when they have two or more chronic conditions that are expected to last at least a year (or until the patient's death) and that place them at significant risk of death, acute exacerbation, or functional decline.
Common Qualifying Conditions
- Diabetes
- Hypertension and heart disease
- Chronic kidney disease
- COPD and other chronic respiratory conditions
- Rheumatoid arthritis and other autoimmune conditions
- Depression and other chronic behavioral health conditions
- Chronic pain conditions
How to Identify Qualifying Patients Systematically
Rather than relying on providers to flag patients ad hoc, running a panel report against your EHR's problem list — looking for patients with two or more qualifying chronic diagnoses — surfaces most eligible patients in one pass.
What Comes After Identifying a Patient
Eligibility is only the first step. The patient needs to provide informed consent, a comprehensive care plan needs to be established, and monthly care coordination time needs to be tracked consistently to bill the program correctly.