A practical guide for selecting the best chronic care management software for physicians, surgeons, and practice leaders
According to the reports, 6 in 10 US adults have at least one chronic disease, and 4 in 10 have two or more. CDC reports also say that almost 90% of America’s national health care spending goes to the people who have chronic and mental health-related conditions.
Chronic care management software gives healthcare practices a structured way to cover that gap, because patients who have chronic conditions spend more time at home than in the exam room.
In this guide, we will explain what chronic care management software does, what features are required for a practice, and how to choose software that reduces your workload.
Quick answers about chronic care management software
- Chronic care management (CCM) is a Medicare Part B service for patients with two or more chronic conditions. It consists of non-face-to-face care coordination between office visits.
- Chronic care management software is a platform that documents care plans, records consent, tracks clinical time, and organizes patient outreach for a CCM program.
- CMS pays for CCM under the Medicare Physician Fee Schedule. Each patient must meet clinical eligibility criteria, give documented consent, and have a comprehensive care plan.
- A practice can run CCM in-house with chronic care management software or hand daily operations to an outside partner that supplies trained staff.
- An EHR stores the chart. A dedicated CCM tool turns that chart into monthly workflows, time logs, and billing records.
What is chronic care management software?
The core job of chronic care management software is to connect clinical activity to Medicare’s document requirements. The platform stores a comprehensive care plan for each patient and keeps it current. It records every minute of clinical staff time against the correct patient and calendar month.
It captures verbal or written patient consent and stores it for audits, and it organizes the monthly call list and summarizes completed work for billing. Billing staff get the records that match what the claim says, and physicians get a clear view of each patient’s status
Many practices also pair CCM software with remote patient monitoring so that the care plan rests on daily home readings and not only on monthly phone calls.
Medicare requirements every CCM program must meet
These are the requirements every software for chronic care management has to support.
| Entity | Requirement | Value |
| Initiating visit | Timing | Required before CCM begins, per the CMS booklet |
| Patient consent | Format | Verbal or written, documented in the medical record |
| Care plan | Scope | Comprehensive, shared with the patient or caregiver |
| Patient access | Availability | 24/7 for urgent needs |
| EHR | Technology standard | Certified EHR technology |
| Billing practitioner | Limit | One practitioner may bill CCM for a patient in a given month |
| Cost sharing | Applies to patient | Yes, Part B deductible and coinsurance apply |
Patient has the right to stop CCM at any time, and physicians must tell patients about cost sharing.
CMS also notes that CCM cannot be billed alongside certain overlapping services, such as specific dialysis-related codes (CPT 90951 through 90970). Confirm current rules with your billing team or your Medicare Administrative Contractor before launching.
CCM CPT codes at a glance
Each CCM CPT code has its own time and staffing rules. Mediremote maintains a reference on chronic care management CPT codes.
Time thresholds are strict. Unlike some time-based services, CCM codes do not use a midpoint rule. If the minimum is not met, the code cannot be reported. Also, 99491 cannot be billed in the same month as 99487, 99489, or 99490.
This is the exact area where chronic care management software earns its keep. Minutes logged by hand on paper or in scattered notes are easy to lose and hard to defend in an audit. A system that timestamps activity creates a clean record.
Key features of chronic care management software
Not every chronic care management platform covers all of these; healthcare administration staff or physicians should look for these.
1. Patient registry and eligibility identification
The platform has to identify patients with two or more qualifying conditions. A searchable registry lets staff build a call list without combing through charts one at a time.
2. Comprehensive care plan tools
The system should come up with a plan that covers problems, medications, symptom management, planned intervention and community resources.
3. Consent capture
The platform should record who consented, when, how, and after what explanation of cost sharing. A missing consent record is one of the quickest ways to lose a claim in an audit.
4. Time tracking by activity
Accurate time logs separate a defensible claim from a risky one. Look for tools that tie each minute to a staff member, a patient, a date, and a type of activity.
5. Outreach workflows
The core of a CCM program is monthly calls. Software should record call outcomes and flag those not yet reached.
6. EHR integration
CMS requires certified EHR technology for chronic care management software. Integration reduces double entry and keeps the care plan visible to every clinician who treats the patient.
7. Reporting and billing summaries
A monthly summary is required for billing staff that shows which patients met which code thresholds. The best chronic management tool gives the summary without manual reconciliation.
8. Security and privacy
You have to ask vendors how they control access and encrypt data because the system that is handling protected health information must follow the HIPAA rules.
Does your practice need chronic care software, or can your EHR do the job?
There are so many EHRs that include care management modules, so it depends on the volume of a practice and how much staff they have.
The main purpose of an EHR is to document encounters and what happens during the visit. Staff have to reach patients on schedule and keep plans current across dozens or hundreds of patients.
Chronic care software built for this purpose organizes those moving parts. If your EHR already supports consent capture, cumulative time tracking, care plan sharing, and monthly reporting, you may not need a separate product. If it does not, a dedicated system closes the gap. Either way, check that the two systems exchange data cleanly.
Software-only versus service-based CCM models
Physicians have to select the chronic care management software model based on the work it performs, not its design.
The software-only model
With chronic care management software on its own, your staff runs the program. Nurses or medical assistants make the calls, update the care plans, and log the time. The software supports them.
This model gives you full control. It also puts every task on your payroll: enrollment calls, monthly outreach, follow-up on missed contacts, and billing preparation.
The service-based model
In a service-based model, the partner supplies trained staff and operational support as well as software. Your physicians still direct care. The partner handles administrative and outreach work.
| Factor | Software-only | Service-based |
| Who makes monthly calls | Your staff | Partner’s care coordinators |
| Who tracks time | Your staff, using the software | Partner, with logs delivered to you |
| Staffing needs | Additional internal hours | Minimal additional internal hours |
| Level of control | Highest | Shared, with physician direction |
| Upfront cost | Often lower | Varies by contract |
| Scalability | Limited by your staff | Limited by contract and partner capacity |
Neither model is right for every practice. A group with spare nursing capacity and a strong billing team may do well with software alone. A busy practice with a thin staff may find that a program built on software with no one to run it never gets off the ground.
When comparing chronic care management companies, ask a direct question: after the software is installed, who makes the calls?
What Mediremote does for your healthcare practice
Mediremote is a software-powered operational partner that provides services to take the administrative burden off the clinical team. Our chronic care management program is built around a clear division of labor.
| Entity | Attribute | Value |
| Device logistics | Method | Pre-configured cellular devices delivered to the practice or facility for patient distribution |
| Patient setup | Support | Call to the patients to help in taking accurate readings |
| Missing readings | Follow-up | Calls when a patient goes three or four days without a reading |
| Daily review | Process | Trained monitors review incoming data and filter false alarms |
| Escalation | Destination | True clinical alerts go to the practice’s triage nurse |
| Time tracking | Precision | Care minutes logged to the second |
| Billing support | Output | Summarize monthly CPT for the billing department |
We do not tell physicians how to treat patients; our role is to handle logistics, data screening, and documentation
Why the device design matters
The devices use built-in cellular connectivity. Patients do not need Wi-Fi, Bluetooth pairing, or a smartphone app. For older adults, who make up much of the CCM population, fewer setup steps mean fewer failed readings and fewer calls back to the clinic.
Our infrastructure is HIPAA-compliant, and it achieves a clean claims rate above 97%. As with any vendor claim, ask for supporting documentation during evaluation. We serve practices in Texas, California, Michigan, Arizona, Missouri, Oklahoma, Idaho, Tennessee, and New York.
Chronic care management software pricing
Chronic care management software pricing varies by vendor, model, and contract. We do not have fixed pricing; it would be great if you request a quote.
What to look for in the best chronic care management software
Not all products suit every clinic; the best chronic care management software depends on your patient volume, how many staff you have, and your billing process. Use this five-step method.
Define your capacity. How many hours each week of administration and nursing do you assign to CCM?
Choose your model. You have to decide whether software or a service-based partner is right for you
Verify compliance support. Confirm the system handles consent, care plans, time logs, and HIPAA safeguards.
Check integration. Ask how the platform connects to your EHR and billing system.
Request a demonstration. Watch the workflow with your own use cases, then speak with a current client in a similar specialty.
If companies are already working in your niche, you have to go with the same chronic care management software because we think specialty matters.
Mistakes to avoid when selecting CCM software
You don’t have to make these mistakes because even big practices make these errors sometimes when choosing a care management platform.
Purchasing chronic care management software prior to defining staffing.
A platform with no one assigned to run it produces little value. Software records care plans and time, but nurses or coordinators must still call patients each month, so decide who owns outreach first.
Overlooking patient usability.
You have to go for cellular equipment that does not require Wi-Fi or a mobile phone app. The main reason is that many patients are older, and devices that are difficult to use frustrate patients, which causes missed readings and dropped enrollments in a chronic care management software.
Neglecting consent specifics.
Poor consent records lead to audits. Providers are required to obtain written or verbal consent and document it in the medical record by Medicare. Patients must also be informed about cost sharing and their right to disenroll from the service at any time.
Loosely tracking time.
Estimates do not meet medicare documentation requirements. For CPT 99490, clinical staff time must be the first 20 minutes of the month. CCM codes do not allow for a midpoint rule; every minute of care coordination counts and must have a timestamped note.
Thinking billing will figure itself out.
Make sure your chronic care management tools handles code thresholds, add-on codes, and same-month restrictions. You cannot bill CPT 99491 in the same month as 99487, 99489, or 99490. Only one practitioner may bill for CCM per month.
Final thoughts on chronic care management software
Chronic care management is a clinical service, a compliance task, and an operations project at the same time. Chronic care management software helps with the documentation and workflow. It does not replace the people who contact patients each month.
Start with a plain question: Who will do the work? The right software can help, if your team can handle it. But if not, a partner on a service basis can do the day-to-day stuff, and physicians are still in total control of all the clinical decisions.
Either way, check the details. Confirm consent capture, care plan tools, time tracking, EHR integration, and security. Compare total costs. Ask for references.
Ready to see how a service-based model could work in your practice?
Request a demo with Mediremote or speak with the team about your patient population and staffing, and how our chronic care management software works best for you.
Frequently asked questions
What software is used for chronic care management?
Practices use chronic care management software to run a CCM program. The platform stores each patient’s care plan, records consent, tracks clinical staff time, and organizes monthly outreach
Do we need to hire extra staff to run CCM?
Yes, because your team makes the calls and logs the time. With a service-based partner such as Mediremote, the partner’s coordinators deliver CCM services and handle daily operations.
How much does chronic care management cost?
Common structures include a per-patient monthly fee, a flat platform fee, a share of reimbursement, and setup or device fees.
What is the best chronic care management software?
The best chronic care management software depends on whether your practice wants a standalone software platform, a unified multi-program system, or a fully managed service.
What are the CCM reimbursement rates for 2026?
The Centers for Medicare & Medicaid Services (CMS) sets payment through the Medicare Physician Fee Schedule; you have to check there.