No patient slips through the cracks.

Most of a primary care practice's Medicare panel is managing more than one long-term condition. A CDC analysis of about 31 million fee-for-service Medicare beneficiaries found that 68 percent had two or more chronic conditions, and more than a third had four or more. CMS's own chronic conditions data put the share at 69 percent in 2017.

That group drives nearly all Medicare spending. In the same CDC analysis, beneficiaries with two or more chronic conditions accounted for 93 percent of it.

68%

had two or more chronic conditions (CDC, 2010 data)

36%

had four or more

93%

of Medicare spending went to patients with two or more

These are the patients CCM was designed for, and the ones whose problems are easiest to catch early between visits.

SourcesCDC, Preventing Chronic Disease (2013)Lochner and Cox, Medicare multiple chronic conditions (PMC)

A few years after Medicare began paying for CCM, the CMS Innovation Center had Mathematica evaluate it using complete Medicare claims from 2014 to 2016, comparing patients who received CCM with similar patients who did not.

Medicare spending for CCM patients fell by about $74 per patient per month over 18 months. Most of the savings came from fewer inpatient stays and less post-acute care, even as payments to physicians went up. CCM patients also had fewer hospital admissions for diabetes, COPD, urinary tract infections, and pneumonia.

~$74

lower Medicare spending per patient per month, 18 months in

4

conditions with significantly fewer admissions: diabetes, COPD, UTI, pneumonia

Uptake was the weak spot: by the end of 2016, about 684,000 patients had received CCM, out of roughly 35 million who were eligible. Summaries of the evaluation report the 18-month figure as $72 to $74.

SourcesPYA, CCM white paper summarizing the CMS evaluation (2018)MGMA, Chronic care management

In September 2024, the HHS Office of Inspector General reported on how remote patient monitoring is used in Medicare. Use grew sharply: from about 55,000 enrollees in 2019 to more than 570,000 in 2022, with Medicare payments rising from about $15 million to about $300 million.

The OIG found that about 43 percent of enrollees who received RPM did not receive all three of its components: education and device setup, the device supplying data, and treatment management time with a clinician.

• The OIG recommended more oversight of who orders RPM and what is monitored
• Its data reflects what was billed; a component may have been delivered but not billed
• Practices billing RPM should be able to show all three components for each patient

Continuum documents device setup and education, the days of readings, and nurse treatment time for every patient, every month, so each RPM claim is backed by the record.

SourcesHHS-OIG, OEI-02-23-00260 (Sept. 2024)Texas Medical Association summary

CMS sets out what a practice has to do to bill CCM in its Medicare Learning Network booklet. The core of it is short.

• The patient has two or more chronic conditions expected to last at least 12 months, or until death, that put them at significant risk
• An initiating visit (an Annual Wellness Visit, Welcome to Medicare visit, or office visit) is required for new patients and those not seen within the past year
• The patient agrees to CCM, and that consent is documented; they are told about cost sharing and that they can stop at any time
• There is a comprehensive care plan in the electronic record, shared with the patient
• The patient can reach someone with access to their record 24 hours a day, with a designated care team member for continuity

Continuum handles the enrollment conversation, consent documentation, care plans, and monthly time logs; your practice keeps billing under its own NPI.

SourcesCMS MLN booklet: Chronic Care Management Services (June 2025)

CCM and the other care management programs are Medicare Part B services, so the usual Part B deductible and coinsurance apply. Many patients have supplemental coverage, such as a Medigap plan or Medicaid, that covers some or all of that.

Because cost sharing applies, the patient has to be told about it when they agree to the program, and they can stop at any time. Our nurses cover this in the enrollment call, in plain language, so there are no surprises on a statement.

SourcesMedicare.gov: Chronic care management servicesCMS MLN booklet: Chronic Care Management Services (June 2025)

Medicare pays primary care practices to manage behavioral health conditions alongside everything else, without sending every patient out for a referral.

General BHI (CPT 99484) covers at least 20 minutes a month of care management for a mental health, behavioral health, or substance use condition that the billing practitioner is treating. It can be delivered by clinical staff such as nurses under general supervision. For more complex cases, the psychiatric Collaborative Care codes (99492 to 99494) add a behavioral health care manager and a psychiatric consultant.

• An initiating visit is required for new patients and those not seen within the past year
• Part B coinsurance applies
• Time spent on psychotherapy can't also be counted toward BHI time

SourcesAIMS Center (University of Washington), CMS BHI and CoCM quick guide

The Annual Wellness Visit is more than a yearly checkbox. It's where preventive care, risk identification, and patient rapport come together, and it sets up better chronic disease management all year.

• Patients get standards-based preventive care
• Current and potential health and safety risks are identified
• Builds patient engagement and rapport
• Supports higher care-quality performance

$136K+

potential new-service revenue from 500 initial AWVs, based on real-world coding examples

$64K+

potential annual revenue from 500 subsequent AWVs

69%

of fee-for-service Medicare patients had two or more chronic conditions in 2017, per CMS

The AWV, or a timely follow-up, is the ideal moment to introduce PCM, CCM, RPM, RTM, or BHI. That keeps preventive care going year-round and adds a straightforward new revenue line.

CMS's 2026 rules shift from measuring participation to measuring reliability: tighter benchmarks, continuous quality monitoring, and far less tolerance for variation in how care gets delivered.

• Centralizing CCM, RPM, PCM, RTM, and BHI supports the consistent patient record CMS expects
• Reaching rising-risk patients early is where avoidable costs are prevented
• Standardized enrollment and documentation reduce site-to-site variation

40–50%

enrollment reported by organizations that centralize care coordination

Continuum plugs into your ACO's care management strategy with RN-led enrollment and monthly monitoring, standardized and audit-ready across every practice in your network.