Chronic Care Management • Medicare Reimbursement

Chronic Care Management ThatDrives Better Outcomes and Revenue

Deliver proactive, coordinated care for patients with chronic conditions while maximizing Medicare reimbursement through automated time tracking and compliant documentation.

DocToDoor CCM enables your care team to manage patients with diabetes, hypertension, heart failure, COPD, and other long-term conditions through structured care plans, regular check-ins, and seamless device integration.

Why Choose DocToDoor CCM

Comprehensive Chronic Care
Management Solution

Holistic Chronic Care Management

Manage patients with multiple chronic conditions through a coordinated, evidence-based care model that improves outcomes and reduces hospitalizations.

Proactive Patient Engagement

Keep patients actively involved with automated reminders, structured assessments, care plan updates, and secure multi-channel communication.

Optimized Revenue Capture

Automatically track and log time spent on CCM-eligible activities, ensuring accurate billing for CPT codes 99490, 99491, and other relevant CMS codes.

Seamless RPM Integration

Combine CCM with your existing Remote Patient Monitoring setup. Monitor patient vitals in real-time while coordinating care, all within one unified platform.

Data-Driven Clinical Decisions

Leverage patient vitals, submitted assessments, medication adherence data, and care plan progress to make informed clinical decisions and measure outcomes.

Unified Platform Experience

Unlike point solutions, DocToDoor integrates CCM with RPM, telehealth, and care coordination tools. One platform, one login, seamless workflows.

Core Features

Everything You Need for
Effective CCM Management

Comprehensive Care Planning

Create personalized, evidence-based care plans with specific goals, medication management, and monitoring schedules.

Disease-Specific Assessments

Deploy structured questionnaires designed for diabetes, hypertension, heart failure, COPD, and other chronic conditions.

Automated Time & Activity Tracking

Intelligently capture time spent on calls, messaging, and care coordination for accurate CCM billing.

Secure Multi-Channel Communication

Connect with patients through HIPAA-compliant messaging, phone calls, or video consultations.

Connected Device Integration

Seamlessly integrate vitals from Bluetooth devices, Apple Health, Google Fit, Withings, and Fitbit.

Care Team Collaboration

Enable nurses, coordinators, and physicians to collaborate on patient plans and coordinate follow-ups.

Reporting & Billing Dashboard

Generate comprehensive monthly CCM reports and billing summaries aligned with Medicare guidelines.

Benefits for Your Practice

Transform Your Chronic Care Program

DocToDoor CCM delivers measurable improvements in patient outcomes, revenue, and operational efficiency.

Improved Patient Outcomes

Empower patients through regular engagement and structured care. CCM helps reduce hospitalizations and improves medication adherence.

Revenue Growth

Capture and bill for non-face-to-face care. Automated time tracking ensures you don't miss billable activities.

Scalable Workflow

Whether you're a small clinic or large health system, our CCM solution scales with flexible workflows.

Regulatory Compliance

Built-in compliance features ensure documentation and billing practices align with Medicare CCM guidelines.

How It Works

Your CCM Workflow in
Five Simple Steps

01

Patient Identification & Enrollment

Identify Medicare-eligible patients with two or more chronic conditions. Obtain consent through DocToDoor's streamlined enrollment process.

02

Comprehensive Care Planning

Develop individualized care plans using templates or custom plans. Set goals, medication schedules, and monitoring requirements.

03

Monthly Care Coordination

Conduct regular check-ins via secure messaging, phone, or video. Document interactions and automatically track time for billing.

04

Device Monitoring & Data Integration

Patients submit vitals using connected devices. Data flows automatically into the dashboard for review and care plan adjustments.

05

Billing & Reporting

Generate monthly CCM billing reports with detailed time logs. Export documentation to your billing system or EMR.

Compliance & Reimbursement

Medicare-Compliant
Billing & Documentation

Billing Requirements

  • Non-Complex CCM (CPT 99490)

    Billable once per calendar month when at least 20 minutes of clinical staff time is spent on CCM activities.

  • Complex CCM (CPT 99491)

    Higher reimbursement available for more time-intensive cases requiring physician involvement.

  • Additional Codes

    Support for CPT 99487, 99489, and other relevant CMS codes based on service complexity.

Documentation Standards

  • Comprehensive, individualized care plans
  • Detailed interaction logs with timestamps
  • Accurate time tracking for all CCM activities
  • Patient consent documentation
  • Medication management records
  • Assessment results and care plan updates
Frequently Asked Questions

Common Questions About
Chronic Care Management

Ready to Transform Your CCM Program?

Partner with DocToDoor to build a scalable, compliant, and profitable Chronic Care Management program that benefits both your practice and your patients.