Chronic Care Management Solutions

Proactive Patient Care & Higher Reimbursements Made Easy

Create patient-centered care plans for Medicare patients with chronic conditions.  

Improve patient care and increase revenue through resource-friendly, seamlessly integrated processes. 

Improving Your Reach. Improving Their Lives.

According to the CDC, 60% of Americans are suffering from at least one chronic condition. In 2030, it is estimated that 170 million Americans will be diagnosed with one or more chronic conditions by 2030. 

With the Remote Patient Monitoring (RPM) market set to continue its health growth rate of 26.7% until the end of the decade, it’s clear to see that telehealth and remote monitoring will become a standard expectation of patients when it comes to value-based care.

By harnessing the expertise of our teams and their industry-leading technology to provide round-the-clock monitoring of your most vulnerable patients’ health, you’ll not only elevate patient well-being but also boost financial growth—fostering a win-win partnership for better health and financial prosperity.

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A Chronic Care Management Platform to Protect Your Patients and Resources

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No-Upfront Investment

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Fee For Successful Reimbursement Only

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Complementary Claims Submission & Billing

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A Win-Win Partnership for Better Health & Financial Prosperity

Chronic care management solutions are increasingly integrating assessments of social determinants of health to tailor care plans that address the broader environmental and social factors affecting patients’ health outcomes. But the benefits extend toward the provider side, too. Apart from improved health outcomes for their patients, healthcare providers receive risk-free revenue without requiring additional resource investments. 


Patient Benefits

Our service promotes proactive management of chronic conditions for improved overall well-being.

Patients’ vitals are tracked round-the-clock, fostering peace of mind and timely interventions whenever health concerns arise.

Through educational resources and close monitoring, patients are empowered to take control of their health, leading to better health outcomes and improved quality of life.

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Provider Benefits

Our service streamlines patient data collection, enabling efficient care coordination and reducing administrative burdens.

Healthcare providers can expand their revenue through reimbursable chronic care coordination services, adding a consistent source of income.

Providers can foster deeper patient relationships and loyalty by offering extended care support, resulting in improved patient satisfaction and a strong reputation within the community.

How Does It Work?

The benefits to both patients and providers become very clear when we start considering the numbers. 

Let’s have a look at how both sides of the service can benefit.

Improved Health

Chronic Care Management refers to the remote monitoring and support of Medicare beneficiaries above the age of 65, who have multiple (two or more) chronic health conditions.

Healthcare providers utilize our CCM program to coordinate and monitor patients’ health, medication adherence, and lifestyle adjustments, which leads to an improvement in patient health. For their services, healthcare providers are reimbursed accordingly.

Improved Health
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Improved Revenue

CPT code 99490 is a healthcare billing code used for chronic care management (CCM) services. This code is used to bill for non-face-to-face care coordination services provided to patients with multiple (two or more) chronic conditions, expected to last at least 12 months or until death.

New Monthly Revenue QUICK Calculation:

Follow the steps below to get a ballpark figure for new reimbursements.

  1. Determine the number of Medicare patients you have
  2. Take this number and multiply by 0.67
  3. Multiply the answer by $64.02

Why Choose Neolytix As Chronic Care Management Provider?

Neolytix CCM Program seamlessly integrates with your current operations and health systems to deliver Chronic Care Management and Remote Patient Monitoring services without requiring upfront investments, staff training, and operational hiccups. Our exclusive focus on the healthcare industry for over 11 years gave us the expertise to collaborate harmoniously with practice and hospital teams. 

  • Risk-Free Collaboration: No upfront investment for CCM, software, hiring staff, and training 
  • Eligible Patient Identification: We’ll do the legwork of identifying all your patients that are eligible for Medicare Chronic Care Management.  
  • Complementary Claims Submission & Billing: We’ll take care of the claims and submit them to Medicare for reimbursement. We will also resolve any denials on those claims. 
  • Easy EHR Integration: Regardless of your EHR system, Neolytix’s chronic care management platform integrates flawlessly into all of the EHRs in the country, like Epic, Athena, eCW, Cerner, etc. 
  • Device Management & Distribution: Well take care of distributing the Medicare-Approved devices to your patient and take good care of training them.  
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Speak to a Specialist

Schedule a FREE consultation with one of our specialists to learn how Neolytix Chronic Care Management can empower healthcare providers to expand patient care and optimize reimbursement revenue.

Frequently Asked Questions (FAQ’s)

Chronic care management services refer to services that are not provided in person, but rather are offered to Medicare beneficiaries with at least two chronic conditions that are expected to last for a minimum of 12 months or until the patient’s death.

The Centers for Medicare & Medicaid Services (CMS) acknowledges the importance of CCM services as fundamental elements of primary care that enhance wellness and lower healthcare expenditures.

Implementing Medicare Chronic Care Management services can provide several benefits for both patients and healthcare providers. Some reasons why Medicare CCM may be beneficial include:

  1. Improved patient outcomes CCM services are designed to help patients manage their chronic conditions and promote better health outcomes. By providing regular check-ins, care coordination, and support, CCM services can help patients avoid complications, reduce hospitalizations, and improve their overall quality of life.
  2. Increased revenue for healthcare providers: By providing CCM services, eligible healthcare providers can receive reimbursement from Medicare, which can help increase their revenue streams. Additionally, providing CCM services can help improve patient satisfaction and loyalty, leading to increased business for the healthcare provider.
  3. Reduced healthcare costs: By helping patients better manage their chronic conditions, CCM services can help reduce healthcare costs associated with hospitalizations, emergency department visits, and other expensive treatments. This can help lower overall healthcare expenditures for both patients and payers.
To qualify for chronic care management (CCM) services, a Medicare beneficiary must have at least two chronic conditions that are expected to last for at least 12 months or until the patient’s death. Examples of chronic conditions that may qualify for CCM services include diabetes, heart disease, hypertension, chronic obstructive pulmonary disease (COPD), asthma, arthritis, dementia, depression, and cancer, among others. 

These physicians and Non-Physician Practitioners (NPPs) may bill CCM services:

  • Physicians
  • Certified Nurse Midwives (CNMs)
  • Clinical Nurse Specialists (CNSs)
  • Nurse Practitioners (NPs)
  • Physician Assistants (PAs)

They must also have an established relationship with the patient and must use an electronic health record (EHR) system that meets certain requirements to document and report the CCM services. Take note of the different codes used for billing between NPPs and physicians.

CPT code 99491: Time only the billing practitioner spends. Clinical staff NPPs’ time doesn’t count.

CPT codes 99487, 99489, and 99490: Time spent directly by NPPs. Practitioner time is also allowed if not billed under 99491 already.

Medicare reimburses for Chronic Care Management (CCM) services on a monthly basis, meaning that eligible healthcare providers can receive payment for each month that they provide CCM services to an eligible patient. It’s important to note that Medicare may also reimburse for additional services provided in conjunction with CCM, such as transitional care management, advance care planning, and annual wellness visits, among others. However, the reimbursement rates for these services may differ from that of CCM services. The rates below are based on national averages.

The CPT codes used to report CCM services are:

  • CPT code 99437 $49.98
    30 additional minutes of provider time (no limit)
  • CPT code 99439 ($47.44)
    Each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with CPT code99490)
  • CPT code 99490 ($62,69)
    Non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.
  • CPT code 99491 $85.06
    CCM services are provided personally by a physician or other qualified health care professional for at least 30 minutes.
  • CPT code 99487 $133.18
    Complex CCM is a 60-minute timed service provided by clinical staff to substantially revise or establish comprehensive care plan that involves moderate- to high-complexity medical decision-making.
  • CPT code 99489 $70.49
    Is each additional 30 minutes of clinical staff time spent providing complex CCM directed by a physician or other qualified health care professional (report in conjunction with CPT code 99487; cannot be billed with CPT code 99490)
Coordinated care transcends the realm of a conventional office visit, especially within the context of Medicare Part B services. While office visits offer essential healthcare interactions, coordinated care delves deeper. It involves proactive strategies to address chronic conditions, minimize acute exacerbation and decompensation, and prevent functional decline. By extending the focus beyond routine appointments, coordinated care under Medicare Part B seeks to enhance patient well-being and quality of life, even as it navigates the sensitive aspects surrounding the eventual passing of the patient.

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