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Chronic Care Management
Turn Chronic Conditions Into Continuous Revenue.
Peerbits builds end-to-end Chronic Care Management systems that automate patient outreach, log billable care minutes, and generate CPT 99490+ claims — turning underserved chronic care patients into a consistent, compliant revenue stream for your practice.
Get a Free CCM Audit$1,800+
Annual CCM revenue per enrolled patient
71M
Medicare beneficiaries eligible for CCM
85%
Avg. reduction in hospitalizations
Standards & Compliance
HIPAA Compliant
CMS CCM Guidelines
CPT 99490 / 99491 / 99487
FHIR R4 Ready
EHR Integrated
Medicare & Medicaid
Most Practices Are Leaving Millions in Eligible CCM Revenue Uncollected
CMS created CCM billing codes in 2015 specifically to fund chronic care coordination — yet fewer than 5% of eligible practices actively bill for it. Here's why, and what it's costing you.
BILLING BARRIER
Manual Time-Tracking Burden
CCM billing requires documenting at least 20 minutes of non-face-to-face care per month per patient. Manual logging is error-prone, audit-vulnerable, and time-consuming — so most practices simply don't do it.
Less than 3% bill CCM
CARE COORDINATION
Uncoordinated Chronic Disease Management
Patients with two or more chronic conditions account for 71% of all Medicare spending. Without structured care coordination, they cycle through ED visits, hospitalizations, and specialist appointments without any continuity.
71% of Medicare spend
REVENUE LOSS
Massive Missed Revenue Potential
A practice with 500 eligible CCM patients that bills successfully can generate $750,000+ in additional annual revenue — recurring, non-visit-based income with no additional physician time required.
$750K+ unrealized per practice
REVENUE CALCULATOR
Your CCM Revenue Opportunity
Based on typical practice panel composition
Eligible Medicare patients
500
in a typical panel
CPT 99490 reimbursement
$62/mo
per enrolled patient
Complex CCM (99487)
$130/mo
for complex patients
Annual revenue at 80% enrollment
$595K+
recurring annually
CCM revenue is non-visit-based — it flows every month for every enrolled patient, regardless of whether they come into the office. Peerbits automates the entire enrollment and billing workflow.
CCM Systems Designed for Every Care Setting
Chronic care management looks very different in a primary care practice versus a health system or specialty group. Our platform is configured for your exact patient population and workflow.
The highest-density CCM opportunity — large panels of elderly, multi-chronic patients who qualify for monthly billing. We automate enrollment, outreach, documentation, and claims end-to-end.
Agent solves:Time-tracking burden, enrollment friction, documentation for audit
Diabetic patients with comorbidities (CKD, neuropathy, retinopathy) qualify for Complex CCM (CPT 99487) at significantly higher reimbursement. We identify and enroll them automatically.
Agent solves:Complex CCM identification, HbA1c tracking integration, care plan automation
CHF, CAD, and hypertension patients require frequent monitoring and care plan updates — all billable CCM activities. We integrate with remote monitoring devices to auto-log care minutes.
Agent solves:Readmission prevention, remote monitoring integration, care plan updates
Federally Qualified Health Centers serving high-prevalence chronic disease populations — we configure CCM for FQHC-specific billing rules, UDS reporting, and grant compliance requirements.
Agent solves:FQHC billing rules, UDS CCM reporting, underserved population outreach
CCM is a core quality metric in MSSP and other ACO models. We provide population-level CCM management with analytics that feed directly into your quality reporting and shared savings calculations.
Agent solves:MSSP CCM quality metrics, population risk stratification, shared savings tracking
Virtual care is an ideal delivery channel for CCM non-face-to-face services. We build CCM workflows native to telehealth platforms — automated check-ins, remote monitoring, and care manager workflows.
Agent solves:Virtual CCM delivery, async communication billing, remote monitoring integration
Every CCM & Related Code, Automated
Our platform captures billing across the full spectrum of chronic care management codes — ensuring no eligible minute goes unbilled.
99490
Standard CCM — 20+ minutes/month
Non-complex chronic care management for patients with 2+ chronic conditions. The foundational CCM code — highest enrollment volume, fully automatable.
~$62/month
Medicare reimbursement per enrolled patient
Highest Volume Code
99487
Complex CCM — 60+ minutes/month
For patients requiring complex care plan revision, moderate-to-high medical decision making, and multiple provider coordination. 2x the reimbursement of standard CCM.
~$130/month
Medicare reimbursement per patient
High-Acuity Patients
99491
Physician-Led CCM — 30+ minutes
When the billing physician personally performs at least 30 minutes of CCM work rather than delegating to clinical staff — higher reimbursement for physician-directed programs.
~$84/month
Medicare reimbursement per patient
Physician-Led Programs
99439
Additional CCM — Each 20-min add-on
Add-on code for each additional 20-minute increment beyond the initial CCM threshold. Captures revenue from high-need patients who require extended monthly engagement.
~$47/add-on
Per additional 20-minute increment
Revenue Maximization
99484
Behavioral Health Integration
CCM for patients with behavioral health conditions integrated into primary care — depression, anxiety, substance use disorders co-managed with chronic physical conditions.
~$49/month
Behavioral health CCM reimbursement
Behavioral Health
RPM Bundle
Remote Patient Monitoring (99453–99458)
Combined CCM with RPM Monitoring — we integrate both workflows into a single platform so device-transmitted data automatically contributes to both CCM minutes and RPM claims.
~$150+/month
Combined CCM + RPM per patient
Stacks with CCM
From Patient Identification to Monthly Claim — Fully Automated
Our CCM platform handles every step from identifying eligible patients to generating a compliant, audit-ready claim — with zero additional physician time required.
Monthly care activity timeline
Automated touchpoints for an enrolled CCM patient
Week 1 — Medication review call
8 min logged
Week 2 — Care plan update + labs reviewed
7 min logged
Week 3 — Specialist coordination
Scheduled
Week 4 — RPM data review + check-in
Pending
Month-end — Threshold reached → Claim generated
Auto-billed ✓
20 min
CMS minimum threshold
100%
Audit-ready documentation
STEP 1
Automated eligible patient identification
The system scans your EHR for patients with 2+ chronic conditions and Medicare/Medicaid coverage — generating a ranked enrollment list ordered by revenue potential and clinical complexity.
STEP 2
Consent capture & enrollment
Patients receive a digital consent form (phone, SMS, or portal) explaining the CCM program. Consent is captured, stored, and linked to the patient record — required by CMS before billing begins.
STEP 3
Personalized care plan creation
AI generates a structured, comprehensive care plan for each enrolled patient — documenting goals, medications, conditions, care team members, and follow-up schedule as required by CMS.
STEP 4
Automated monthly patient outreach
Care managers receive automated outreach queues. Patient check-ins are logged via phone, secure messaging, or telehealth — with every minute automatically tracked and timestamped for audit.
STEP 5
Claim generation & billing
Once the monthly threshold is met, the system generates the appropriate CPT code (99490, 99487, 99439, etc.), validates against CMS rules, and submits the claim — automatically.
Everything Your CCM Program Needs to Scale
From a single-clinic CCM program to an enterprise population health deployment — every component built and integrated by Peerbits.
Population Scanning
Eligible Patient Identification Engine
Scans your entire EHR panel for CCM-qualifying patients — ICD-10 chronic condition flags, Medicare/Medicaid coverage, and revenue potential scoring to prioritize enrollment outreach.
CMS Compliant
AI Care Plan Generator
Automatically generates CMS-compliant, patient-specific care plans from EHR data — conditions, medications, goals, care team, and follow-up schedule — ready for physician review and approval.
Audit-Ready
Automated Time Tracking & Audit Log
Every care manager interaction is timestamped, logged by type, and linked to the patient record — creating an airtight audit trail that meets CMS documentation requirements for every claim.
Care Manager Efficiency
Intelligent Care Manager Outreach Queue
Daily prioritized task lists for care managers — sorted by patients approaching the 20-minute threshold, flagged risk events, or overdue follow-ups — so no billing opportunity is missed.
Multilingual & Multi-Channel
Patient Engagement & Reminders
Multi-channel outreach via SMS, voice, secure messaging, and patient portal — in the patient's preferred language and at optimal contact times based on engagement history.
Adherence Tracking
Medication Management & Reconciliation
Medication adherence tracking, refill reminders, interaction flagging, and care manager-guided reconciliation — documented automatically as billable CCM activity.
CCM + RPM Stacking
Remote Patient Monitoring Integration
Native integration with RPM devices (glucometers, BP cuffs, weight scales, pulse oximeters) — RPM data auto-contributes to CCM minutes and generates parallel RPM claims.
Zero-Touch Billing
Automated CCM Billing & Claim Generation
When monthly minute thresholds are met, the system selects the correct CPT code, validates CMS rules, and submits the claim — no coder involvement required for routine CCM billing.
Program ROI Dashboard
CCM Revenue & Quality Analytics
Real-time dashboards tracking enrolled patients, minutes logged per care manager, monthly billing yield, claim acceptance rates, and readmission reduction by cohort.
Real life example of patient engagement software delivered by Peerbits
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Why Peerbits CCM vs. Off-the-Shelf CCM Platforms
Most CCM software gives you a time-tracking tool and leaves the rest to your staff. Peerbits builds a complete CCM engine — enrollment, outreach, billing, and analytics — tuned to your patient population.
Built and owned by you — no subscription trap
No per-patient-per-month SaaS fees that erode your CCM margin. Peerbits builds and delivers a custom CCM system you own outright — the revenue is fully yours as your panel grows.
Embedded in your existing clinical workflow
Eligible patients surface inside Epic, Cerner, or eClinicalWorks — no separate portal for your care managers to log into. Every interaction logged in the EHR, every minute counted.
CMS-compliant care plans in seconds, not hours
Our AI generates a draft, CMS-structured care plan from existing EHR data — physicians spend 2 minutes reviewing and approving rather than 20 minutes drafting from scratch.
Identifies every billable code, not just 99490
Most platforms only bill the basic CCM code. Ours automatically identifies complex CCM, physician-led CCM, add-on codes, and RPM stacking opportunities across your entire enrolled population.
Documentation that survives any CMS audit
Every claim is backed by timestamped interaction logs, care plan version history, consent records, and care team activity — pre-assembled in audit-ready format at the click of a button.
CCM data that feeds your ACO quality metrics
CCM encounter data flows directly into your MSSP quality reporting, risk stratification models, and population health dashboards — making CCM a clinical and financial asset simultaneously.
vs. Prevounce / ChartSpan / Arcadian
Unlike per-PMPM CCM SaaS platforms that take a cut of every claim and give you a generic time-tracker, Peerbits builds a fully integrated, AI-powered CCM system custom-fitted to your EHR and patient population — with no ongoing per-patient fees, full code coverage, and clinical outcome analytics your off-the-shelf vendor can't provide.
What Peerbits CCM Clients Achieve
Measured across active CCM program deployments within the first 6 months of full enrollment.
$1,820
Average annual CCM revenue per enrolled patient
vs. $0 pre-implementation
94%
Monthly CCM billing compliance rate
Industry avg: 60–70%
38%
Reduction in avoidable ED visits
Among enrolled CCM patients
6 wks
Average time to first CCM claim generated
From contract to live billing
What Practice Leaders & Care Teams Say
#clientspeak
Learn more about our processes from our clients
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After a rigorous selection process choosing Peerbits as our technology partner was the right choice. Peerbits is an innovative company with a team of talented, committed, and smart individuals. Thank you for helping us deliver world-class healthcare solutions. Good job.
Dan
Health vector
Your Chronic Care Patients Are Already Eligible
Start with a free CCM panel audit — we'll scan your patient data, identify every CCM-eligible patient, calculate your total revenue opportunity, and show you exactly how to capture it within 6 weeks.
Get My Free CCM Panel AuditFrequently asked questions
Chronic Care Management is a Medicare program that reimburses healthcare providers for non-face-to-face care coordination services for patients with two or more chronic conditions — including care planning, medication management, and monthly patient outreach.
Patients with two or more chronic conditions expected to last at least 12 months, who are covered by Medicare or Medicaid, qualify for CCM. Common qualifying conditions include diabetes, hypertension, heart disease, COPD, and depression.
Our CCM platform is built with end-to-end encryption, role-based access control, audit logging, and secure data storage — fully aligned with HIPAA requirements to protect patient health information at every touchpoint.
Yes. Our platform integrates natively with Epic, Cerner, Meditech, and 25+ EHR systems using HL7 and FHIR APIs — syncing patient data, care plans, and billing records without duplicate entry or workflow disruption.
The cost depends on your EHR environment, required integrations, patient panel size, and billing workflow complexity. We provide a detailed estimate and ROI projection after a free assessment of your practice's CCM opportunity.
Once a patient's monthly care minutes hit the CMS threshold, the platform automatically selects the correct CPT code — 99490, 99487, 99439, or 99491 — validates against payer rules, and submits the claim without any manual coder involvement, ensuring no billable minute goes uncaptured.
Yes. Our platform supports concurrent CCM and RPM billing — device-transmitted data automatically contributes to CCM time logs and generates parallel RPM claims (99453–99458), maximizing reimbursement per patient without additional care manager effort.
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