Chronic Care Management Software That Scales With Every Patient

ChronicCareIQ helps high-volume Medicare practices simplify CCM workflows, identify rising-risk patients between visits, and automatically capture reimbursable non-face-to-face care activity, while keeping CCM connected to RPM, APCM, PCM, TCM, and BHI/CoCM.

4.8

800+ unsolicited patient reviews

What Is Chronic Care Management?

Chronic Care Management reimburses practices for non-face-to-face care provided to patients with two or more chronic conditions between visits, including care coordination, symptom monitoring, and patient follow-up.

Patients with two or more chronic conditions expected to last at least 12 months (or until end of life) that place them at significant risk of decline, with a comprehensive care plan in place.

About $66/month per patient for the base clinical-staff code, 99490, with additional reimbursement available for extended care-management time, provider-delivered CCM, complex CCM, and care-planning add-ons. See the full breakdown below.

CCM Programs Break Down As Patient Enrollment Grows

CCM is simple to understand but hard to scale. Every enrolled patient adds outreach, symptom monitoring, care-plan updates, documentation, time tracking, billing thresholds, and follow-up activity.

As enrollment grows, manual workflows create staff burden, missed documentation, and uncompensated care.

How ChronicCareIQ Simplifies CCM

ChronicCareIQ helps practices operationalize CCM around eligible patients, recurring follow-up, care-plan activity, time capture, documentation, and reimbursement.

Identify, Enroll & Organize CCM Patients

Enroll eligible patients with chronic conditions, and organize patient panels around the ongoing follow-up needs your care team already uses.

Surface Rising-Risk Patients

RiskIQ automatically detects rising critical-event risk in patients, helping care teams prioritize patients who need attention right now.

Automatically Document CCM Activity

ChronicCareIQ captures qualifying care activity and organizes audit-defensible documentation as your team follows up.

Leverages the EHR, phone systems, and connected devices your practice already uses.

Why Care Management Programs Fail As They Grow

How Much Do CCM
CPT Codes Reimburse

CPT Code

What it covers

Time / requirement

Est. monthly reimbursement*

99490

Chronic care management — base

20 min clinical staff time/mo; 2+ chronic conditions; care plan in place

~$66

99439

Add-on to 99490

Each additional 20 min clinical staff time (max 2×/mo)

~$50

99491

Provider-delivered CCM — base

30 min physician/QHP time/mo

~$89

99437

Add-on to 99491

Each additional 30 min physician/QHP time (max 2×/mo)

~$63

99487

Complex CCM — base

60 min clinical staff time/mo; moderate-high complexity decisions

~$144

99489

Add-on to 99487

Each additional 30 min clinical staff time

~$78

G0506

Care-planning add-on

One-time comprehensive care-plan assessment at the initiating visit

~$66

**Estimated 2026 national non-facility Medicare reimbursement. Actual reimbursement varies by geography, payer, site of service, patient eligibility, documentation, and billing circumstances. This content is educational and is not billing, coding, or legal advice.

See Your Reimbursement Potential

Enter your NPI and we'll estimate the recurring monthly revenue your practice could generate from CCM and other programs — based on your real patient population.

Built to simplify chronic care management at scale

80% increase in MIPS scores + $164/hour in reimbursable CCM revenue

Better Weighs to Better Health streamlined day-to-day CCM operations across 271 enrolled patients by consolidating manual workflows into one connected platform.

Reduced manual administrative work

“Our program has an incredible impact on patients, their families, and our office staff. What we do takes multiple tasks off of the entire clinical floor team on a daily basis.”

Kristy Townsend, LPN,
CCM Program Director

Scaled chronic care operations

Practices using ChronicCareIQ have successfully expanded CCM programs while reducing day-to-day administrative work.

Woodside Medical

+12 %

Medicare reimbursement

2,000 %

ROI

Advanced Medical Care

$146 / hour

In reimbursable revenue

2,100

CCM patients

ARcare

3,500 +

Managed CCM patients

1900 %

ROI

See How ChronicCareIQ Supports CCM In Your Specialty

CCM is the foundation most practices start with — but how it’s run depends on the conditions you treat. Find the care-management approach built for your specialty, all on one platform.

Cardiology

Identify meaningful cardiac changes sooner through connected-device readings, symptom tracking, and condition-specific monitoring protocols.

Pulmonology

Track respiratory health between visits through oxygen saturation trends, symptom reporting, inhaler adherence, and treatment response.

Primary Care

Monitor chronic conditions between visits through symptom reporting, blood pressure, glucose, weight, mood, and medication adherence trends.

Nephrology

Monitor kidney health through blood pressure trends, fluid and weight tracking, symptom reporting, and medication adherence.

Neurology

Track neurologic symptoms, mobility changes, medication adherence, and functional status through structured assessments and monitoring.

Gastroenterology

Support ongoing behavioral health care through mood screening, medication adherence monitoring, risk assessment, and condition-specific protocols.

Behavioral Health

Support ongoing behavioral health care through mood screening, medication adherence monitoring, risk assessment, and condition-specific protocols.

Multi-Specialty

Manage multiple chronic conditions from one platform with symptom tracking, medication adherence monitoring, and specialty-specific care protocols.

When Patients Engage, Care Programs Scale

4.8 stars. 800+ patient reviews. Every rating below is unsolicited.
No incentives. No campaigns.

4.8

4.8

ChronicCareIQ has helped tremendously in keeping in touch with our patients on a constant and recurrent basis. It has also helped us improve our quality scores, decrease our emergency room utilization, and also decrease hospitalizations.

Dr. Salma SaigerInternist, Salma Mazhar MD PA Primary Care Clinic

Doctors are not going to be able to live without ChronicCareIQ. The convenience and regular contact with patients is the big key going forward.

Dr. Gary P. JonesThoracic Surgeon, Louisiana Cardiovascular & Thoracic Institute

As a healthcare provider committed to delivering the highest quality of care, ChronicCareIQ has become an indispensable ally in our mission. The platform's impact on patient outcomes, from reducing hospital admissions to enhancing communication and achieving financial success, has exceeded our expectations.

Dr. Jim Carmical MDPrimary Care Physician, Woodside Medical

I’ve really been pleased with our patient retention rate with ChronicCareIQ. Patients are very thankful for it and want to continue using it.

Dr. Brian FlowersCardiologist, Birmingham Heart Clinic

At Chesapeake & Washington Heart Care, we've seen remarkable improvements with ChronicCareIQ. It has greatly enhanced the efficiency of our phone interactions and the promptness in updating patient care. This has been vital in providing timely and effective healthcare services to our patients.

Gina Baxter Chief Operating Officer, Chesapeake and Washington Heart Care

With ChronicCareIQ, we are better in touch with our patients, and patients feel better knowing that they have daily or regular contact with our office. We have also seen a significant decrease in office call volume.

Dr. James WestInternist, Perimeter North Internal Medicine

ChronicCareIQ has helped tremendously in keeping in touch with our patients on a constant and recurrent basis. It has also helped us improve our quality scores, decrease our emergency room utilization, and also decrease hospitalizations.

Dr. Salma Saiger Internist, Salma Mazhar MD PA Primary Care Clinic

FAQ

How does ChronicCareIQ reduce manual CCM work?

ChronicCareIQ helps centralize patient engagement, care-plan documentation, time tracking, call activity, reporting, and billing workflows so CCM does not become a disconnected manual process. The goal is to make CCM easier to manage at scale while supporting compliance and operational visibility.

Which patients are the best fit for CCM?

CCM is generally a strong fit for Medicare patients with two or more chronic conditions expected to last at least 12 months, or until the patient’s passing, and that place the patient at significant risk of decline, hospitalization, or other adverse outcomes. Common examples include diabetes, hypertension, heart failure, COPD, chronic kidney disease, and other long-term conditions requiring ongoing coordination.

How does CCM compare to APCM?

CCM remains useful for practices managing non-face-to-face care for patients with multiple chronic conditions and documenting time-based services. APCM is a newer monthly model that bundles several care-management elements without requiring monthly minute counting. Many practices need help understanding which model fits their patient population, workflows, and reimbursement strategy. ChronicCareIQ can help evaluate the right program mix.

Who performs CCM services?

CCM is commonly performed by clinical staff under the appropriate supervision of the billing provider. ChronicCareIQ software supports in-house care teams by organizing outreach, documentation, time tracking, care plan workflows, and reimbursement activity. If partner support is available, it can be positioned as an optional extension rather than a requirement.

Can CCM be used with RPM, PCM, APCM, RTM, or TCM?

Many practices run CCM alongside other care-management programs, but billing depends on patient eligibility, payer rules, timing, documentation, and avoiding duplicate counting of the same activity. ChronicCareIQ helps keep CCM connected with RPM, PCM, APCM, RTM, and TCM in one platform so practices can manage care coordination and reimbursement workflows more consistently.

How does CCM help practices improve patient care between visits?

CCM gives care teams a structured way to stay connected with patients outside the exam room. Regular outreach can help identify symptoms, medication issues, care gaps, and changes in patient status sooner, giving the practice more opportunities to intervene before the next scheduled appointment.

How does ChronicCareIQ support CCM compliance?

ChronicCareIQ supports CCM compliance by helping practices document patient interactions, track qualifying activity, organize care-management workflows, and maintain clearer visibility into reimbursable work. This helps practices reduce manual tracking burden and prepare more confidently for internal review or payer audit.

Build a modern,  Scalable CCM program