Comprehensive care coordination for patients living with two or more chronic conditions — 20-minute monthly clinical calls, a 24/7 nurse line, and personalized care plans, with every billable minute captured automatically.
Chronic Care Management wraps your highest-acuity patients in continuous, between-visit support — the proactive layer that catches small drifts before they become hospitalizations.
A dedicated clinical staff member checks in every month — reviewing symptoms, vitals and adherence, and adjusting the plan in real time.
Condition-specific goals, medications and self-management steps — documented, shared with the patient, and revisited at every touchpoint.
Patients reach a clinician any hour, any day — guidance that keeps a Sunday-night concern out of the emergency department.
Every prescription, refill and interaction risk reviewed and reconciled — so the medication list reflects what the patient is actually taking.
Every qualifying minute — calls, coordination, chart work — is logged against the patient automatically. No timers, no spreadsheets.
Time, consent and documentation roll straight into audit-ready claims — coded correctly the first time, defensible if a payer ever asks.
patient retention in the CCM program at one year
more billable care minutes captured per eligible patient
fewer avoidable readmissions among actively managed patients
nurse-line coverage keeping urgent concerns out of the ED
Medicare reimburses CCM through a clear set of CPT codes. CareSpace makes sure every eligible minute lands on the right one.
First 20 minutes of non-complex CCM delivered by clinical staff under physician direction. The foundation of every CCM panel.
Each additional 20 minutes of non-complex CCM in a given month — billable when a patient needs more coordination than the base call.
Higher reimbursement for higher-acuity patients requiring moderate-to-high complexity medical decision-making and extended care time.
Recurring, predictable revenue from patients you already see — captured automatically, month after month, without adding visits to anyone's calendar.
If you care for patients with two or more chronic conditions, you already have an eligible CCM population — most practices just aren't capturing it yet.
CCM is built for the chronic, ongoing diagnoses that fill your panel — the patients who benefit most from continuous coordination.
From finding eligible patients to filing a clean claim — CareSpace carries the operational weight so your team carries the care.
CareSpace auto-identifies CCM-eligible patients from your panel and streamlines consent and enrollment — no manual chart review, no eligibility guesswork.
Your care team works from a prioritized queue, building personalized plans and making monthly calls while every minute is documented automatically.
Time, consent and documentation roll into audit-ready claims, coded to the right CPT every time — defensible the moment a payer asks.
Pairs naturally with Remote Patient Monitoring for continuous, device-driven oversight between calls.
Run the numbers on your own population, then see the platform in action. A 20-minute demo is all it takes to map your path to recurring chronic-care revenue.