1. Eligible-Patient Identification
Review your patient population for two or more chronic conditions expected to last at least 12 months. Our CCM Eligibility Calculator is a useful first-pass check.
2-3. Outreach & Consent
Explain the program to the patient and document their consent to enroll, per current CMS guidance — see CCM Patient Enrollment Software for how ChronicSync tracks this.
4. Enrollment
The patient moves into active CCM care management, with enrollment status tracked per patient.
5. Care Plan
An individualized, electronic care plan is created with goals, interventions, and a review schedule — see CCM Care Plan Software.
6. Monthly Activities
Care-team communication, patient outreach, and other non-face-to-face coordination happen throughout the billing period — see CCM Care Coordination Software.
7. Time Tracking
Staff log CCM-qualifying minutes as activity happens, with a running monthly total per patient — see CCM Time Tracking Software.
8. Documentation
Care-plan updates and activity notes stay organized by patient and billing period — see CCM Documentation Software.
9. Monthly Review
Before the billing period closes, review each patient's time or tier status and documentation completeness against billing thresholds.
10. Reporting & Billing Preparation
Organized monthly activity and documentation are ready for your billing team — see CCM Billing Software and CCM Reporting Software.