What Is CCM and Why It Matters for CKD

CCM is a Medicare program that reimburses providers for coordinating the care of patients with two or more chronic conditions expected to last at least 12 months. Since CKD often coexists with diabetes, hypertension, or heart failure, many patients easily qualify.

A compliant CCM program includes:

• Comprehensive care plan stored in a shareable format

• Monthly follow-up with at least 20 minutes of staff or provider time

• Medication reconciliation and adherence support

• Coordination across specialists such as nephrology, cardiology, and endocrinology

• Patient education on diet, fluid balance, and lab monitoring

CCM is billed through codes such as:

• 99490 – 20 minutes of staff time/month

• 99439 – Each additional 20 minutes

• 99491/99437 – Provider personal time

• 99487/99489 – Complex CCM for high-acuity patients

Benefits of CCM in CKD Care

• Improved Blood Pressure and Glycemic Control: Monthly outreach reinforces daily habits that protect kidney function.

• Medication Management: Reconciles multiple prescriptions (e.g., ACE inhibitors, diuretics, phosphate binders).

• Reduced Hospitalizations: Early intervention for fluid overload, infection, or acute kidney injury.

• Holistic Care: Aligns CKD management with comorbidities such as diabetes or heart failure.

• Patient Engagement: Keeps patients accountable with regular check-ins and care team support.

Which Patients Benefit Most

CCM for CKD is especially valuable for:

• Stage 3–5 CKD patients managing multiple chronic conditions

• Patients with frequent medication changes or polypharmacy

• Seniors with cognitive or mobility limitations affecting adherence

• Recently hospitalized patients for CKD-related complications

• Patients preparing for dialysis or transplant who need close monitoring and coordination

What a Monthly CCM Cycle Looks Like

1. Identify Patients – Review panels for patients with CKD plus comorbidities.

2. Care Plan Development – Document treatment goals, lab schedules, diet guidance, and medication list.

3. Monthly Outreach – Staff call to review adherence, symptoms, and follow-up needs.

4. Coordination – Communicate with nephrologists, dietitians, and community resources.

5. Billing & Documentation – Track minutes, document activities, and submit CPT 99490/99439 or 99491/99437.

CCM in Action: A Case Example

Ms. J, a 70-year-old with Stage 4 CKD, diabetes, and hypertension, enrolled in CCM. Each month, her nurse coordinator reviewed her medication list, confirmed diet compliance, and arranged lab follow-ups. When her creatinine trend suggested early decompensation, the coordinator escalated the case to nephrology. Early intervention prevented hospitalization and delayed dialysis initiation.

Implementation Tips

• Train staff on CKD-specific red flags (e.g., sudden weight gain, reduced urine output).

• Standardize care plan templates that include renal labs, diet, and fluid restrictions.

• Educate patients on the link between daily habits and kidney health.

• Combine CCM with RPM (BP and weight monitoring) for tighter oversight.

• Communicate clearly with nephrology teams to avoid duplication of effort.

Key Takeaway

For CKD patients, CCM ensures that care extends far beyond the clinic. By providing monthly touchpoints, medication management, and specialist coordination, practices can slow disease progression, reduce hospitalizations, and improve patient quality of life—all while capturing appropriate reimbursement.