Chronic Care Management Platform

CCM, RPM, RTM, and PCM with automated billing documentation.

CareClinic Compass is an all-in-one platform for chronic care management that enables better coordination, communication, and monitoring of patients’ health. Additionally, it increases practice revenue through enhanced billing and reimbursement opportunities.

CCM provider dashboard displaying patient medication list, care plan overview, and chronic condition monitoring for remote patient management
Patient Monitoring
Care Coordination
Billing Documentation

Key Platform Benefits

Proven to deliver 40% better patient adherence and 2.5 hours daily time savings through automated care coordination, streamlined workflows, and improved patient engagement.

Increase Practice Revenue

CCM services are typically billed on a per-patient, per-month basis (CPT codes 99490, 99491, 99487, 99489), providing a steady stream of revenue that can help stabilize and grow your practice over time. Furthermore, CareClinic automates documentation and billing processes, ensuring accuracy and efficiency.

Improve Patient Outcomes

Enhanced oversight leads to better health outcomes for patients with chronic illnesses while reducing the likelihood of costly hospitalizations or emergency department visits. This proactive approach to care results in higher levels of patient satisfaction and trust in your practice.

Automated Time Tracking

CareClinic automatically tracks patient engagement time and generates billing-ready reports. As a result, there is no more manual documentation of care coordination time. Instead, the platform captures every interaction, ensuring you capture all eligible revenue while minimizing administrative workload for your staff.

Better Care Coordination

Enable real-time, secure messaging and collaboration between you, your patients, and other members of their healthcare team. This streamlined communication ensures everyone involved in a patient’s care is on the same page, leading to more informed decision-making and faster response times.

Care Management Services

Support multiple care management programs with a single platform. Each service improves patient outcomes while generating sustainable revenue.

Complex CCM

Complex CCM is a higher level of chronic care management, designed for patients with more demanding care needs. These individuals typically have multiple chronic conditions requiring significant management, including regular medication adjustments, specialized care plans, and frequent provider interventions.

CPT 99487
CPT 99489
Multiple Conditions

Remote Therapeutic Monitoring (RTM)

RTM allows clinicians to remotely monitor patients’ adherence to prescribed treatments, such as medication usage, inhaler technique, or self-injection practices. By utilizing RTM, you can ensure that your patients are using their medications effectively, leading to better outcomes and reduced hospitalizations.

CPT 98975
CPT 98976
CPT 98977

Remote Patient Monitoring (RPM)

RPM is a vital component of CCM platforms, allowing providers to track vital signs, symptoms, and physiological data from patients in real-time. RPM offers numerous benefits, such as early detection of potential health issues, more accurate assessments, and the ability to make timely adjustments to treatment plans.

CPT 99453
CPT 99454
CPT 99457

Principal Care Management (PCM)

PCM is a specialized service for patients with a single, high-risk chronic condition. PCM focuses on the comprehensive management of that specific condition, coordinating care and resources to optimize patient health. This focused approach can improve patient outcomes while boosting your practice’s revenue through appropriate billing.

CPT 99424
Single Condition
High-Risk

Real-World Use Cases

Real healthcare organizations use CareClinic Compass to manage chronic conditions across multiple specialties. From diabetes to behavioral health, see how providers reduce hospitalizations and improve patient adherence.

Diabetes Management

Consider a patient with diabetes who struggles to maintain their blood sugar levels within the recommended range. By utilizing Remote Patient Monitoring, you can closely monitor their glucose readings, promptly identifying any concerning trends and adjusting their treatment plan as needed. This proactive approach can result in better blood sugar control, improved patient outcomes, and a reduced risk of costly complications.

Congestive Heart Failure

A patient with congestive heart failure requires close monitoring and frequent adjustments to their medication regimen. Through Complex CCM, you can develop a comprehensive care plan, coordinate with other healthcare providers, and ensure that the patient receives the necessary interventions to manage their condition effectively. By leveraging CCM capabilities, you can optimize the patient’s care while increasing billing and reimbursements through appropriate coding.

Mental Health Conditions

For patients managing depression, anxiety, or bipolar disorder, consistent mood tracking and medication adherence are critical. CareClinic enables providers to monitor daily symptom patterns, medication compliance, and triggers that may indicate deterioration. Early intervention based on tracked data can prevent hospitalization and improve quality of life.

Respiratory Conditions

Patients with COPD or asthma benefit from RTM to track inhaler usage and technique. The platform monitors adherence patterns and can alert providers when patients miss doses or show signs of exacerbation. Proper inhaler technique education combined with monitoring can significantly reduce emergency room visits and improve lung function.

Chiropractic & Chronic Pain

Chiropractors and pain management specialists use Compass to track pain levels, mobility improvements, and exercise compliance between visits. Patients log their daily pain scores, complete home exercises, and document treatment responses, enabling providers to adjust care plans based on real data rather than recall at appointments.

Dermatology Care

Dermatology practices monitor skin conditions through photo-based progress tracking and medication adherence. Patients document flare-ups, track topical application schedules, and upload progress photos, helping providers identify triggers and adjust treatment protocols without requiring frequent office visits.

IBS & GI Conditions

Gastroenterology practices help patients identify food triggers and symptom patterns through detailed tracking of meals, symptoms, and bowel movements. The platform’s analytics reveal correlations between diet, stress, and symptom severity, enabling personalized dietary recommendations and more effective treatment strategies.

Behavioral Health

Mental health providers track therapy homework completion, medication adherence, and daily mood patterns. Crisis alerts notify providers when patients report severe symptoms, enabling timely intervention. Between-session monitoring provides richer context for therapy sessions and medication management decisions.

Works Worldwide

CareClinic Compass is valuable for any healthcare organization, delivering 40% improved patient adherence, 2.5 hours of daily time savings, and superior outcomes regardless of billing capabilities. Perfect for international providers, chiropractors, behavioral health, dermatology, GI specialists, and any practice focused on chronic condition management.

How It Works

1. Enroll Patients

Identify eligible patients with chronic conditions and enroll them in your CCM program. Patients download the CareClinic mobile app and start tracking their health data immediately with no complex setup required.

2. Monitor Patient Data

Access the Compass provider dashboard to view patient-reported data, vital signs, medication adherence, and symptoms in real-time. Set alerts for concerning trends that require clinical intervention.

3. Improve Outcomes

Track patient progress and health trends over time. Early intervention based on real-time data helps prevent complications, reduce hospitalizations, and improve quality of life for patients with chronic conditions.

Additional Benefits

Beyond better outcomes and increased revenue, CareClinic Compass streamlines operations and enhances the care experience.

Data Analytics & Reporting

Your practice can benefit from robust data analytics and reporting capabilities. These tools help you identify patterns and trends in patient care, as well as areas for improvement. This data-driven approach leads to more effective resource allocation, targeted interventions, and continuous improvement in the quality of care that your practice provides.

Intelligent Alerts & Crisis Prevention

Set instant alerts for abnormal vital signs, missed medications, or concerning symptom patterns. Crisis intervention alerts notify providers when patients report severe mood changes or dangerous symptoms, enabling timely intervention before emergencies occur. Automated reminders ensure patients never miss critical medications or appointments.

Multi-Platform Accessibility

Patients access the platform seamlessly across iOS, Android, and web browsers, ensuring they can track their health anytime, anywhere. Providers access the same real-time data through the Compass dashboard on any device. This cross-platform approach ensures no patient is left behind due to technology constraints.

Population Health Analytics

Health systems and large practices gain visibility across their entire patient population with quality metrics reporting, risk stratification tools, and performance dashboards. Track HEDIS and CMS compliance metrics, identify high-risk patients requiring intervention, and allocate resources effectively based on real-time analytics.

Frequently Asked Questions

What is chronic care management (CCM)?+
Chronic care management is a Medicare program that reimburses providers for coordinating care for patients with multiple chronic conditions. It includes remote monitoring, care planning, and medication management to improve patient outcomes.
How does CCM billing work?+
CCM billing requires 20+ minutes of non-face-to-face care coordination per month per patient. Providers use CPT codes 99490, 99491, 99487, and 99489, with reimbursement ranging from $65-125 per patient monthly.
What CPT codes are used for chronic care management?+
CCM uses CPT codes 99490 and 99491 for basic services, 99487 and 99489 for complex CCM, 99453-99457 for remote patient monitoring, and 98975-98977 for remote therapeutic monitoring.
Can I use CCM software without billing Medicare?+
Yes, CCM platforms improve patient outcomes and reduce administrative burden regardless of billing. Many international providers and specialists use these tools exclusively for care coordination without Medicare reimbursement.
How does remote patient monitoring work?+
Remote patient monitoring uses digital devices to collect patient health data outside clinical settings. Providers receive real-time alerts for abnormal readings and can intervene before conditions worsen.
What are the benefits of CCM for patients?+
CCM improves medication adherence by 40%, reduces hospitalizations, provides 24/7 access to care teams, and helps patients better manage chronic conditions through consistent monitoring and support.
Does CCM software integrate with EHR systems?+
Most CCM platforms support FHIR-based integrations with major EHR systems like Epic, Cerner, and Allscripts. Data can be exported in PDF, CSV, or FHIR formats for seamless workflow integration.
Is CCM platform data HIPAA compliant?+
Yes, reputable CCM platforms are HIPAA compliant with 256-bit encryption, secure cloud storage, regular security audits, and business associate agreements to protect patient health information.

Ready to Transform Chronic Care Management?

See how CareClinic Compass can help your organization improve patient outcomes, increase CCM reimbursement, and reduce administrative burden through automated care coordination and billing documentation.