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Chronic Care Management

A Simple, Scalable Solution for Chronic Care Management

1 : Insurance Verification

2 : Patient Enrollment

3 : Care Plan Development

4 : Ongoing Care Coordination

5 : Regular Follow-Ups

6 : Clinical Documentation & Reporting

7 : Monthly Billing

8 : Quarterly Program Review

Have questions about Remote Patient Monitoring (RPM), Chronic Care Management (CCM), Genetic Testing, or Wound Care partnerships?

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A SIMPLE SCALABLE SOLUTION FOR CHRONIC CARE MANAGEMENT

Multilingual Clinical Team

  • Ensures every patient feels heard and supported
  • Improves engagement
  • Makes them active participants in their care

    • Omni-Channel Communication

  • MoonMD provides simple and direct communication tools
  • Secure messaging through our app
  • Phone
  • Keeping patients connected to their care wherever they are

    • Compliant Billing & Reporting

  • Our platform’s built-in compliance tools streamline billing and reporting
  • Reducing administrative burden
  • So your team can focus on what matters most— patient care.
  • Ensuring accuracy

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    • Chronic Care Management Programs (CCM)

    Chronic Care Management (CCM)

    Stay connected to your patients between visits with our Chronic Care Management program. MoonMD helps providers improve outcomes, enhance compliance, and increase revenue through ongoing, personalized patient support.

    What is CCM?

    Chronic Care Management (CCM) enables healthcare providers to deliver continuous, coordinated care to patients with one or more chronic conditions. Through regular communication, personalized care plans, and proactive follow-ups, CCM helps patients manage their health more effectively—reducing hospital visits and improving long-term outcomes.

    Benefits of CCM

    • Improved management of chronic conditions through continuous care
    • Reduced hospitalizations and emergency visits
    • Enhanced patient engagement and adherence to care plans
    • Personalized treatment and medication adjustments based on ongoing assessments

    READY TO TRANSFORM PATIENT CARE WITH CCM?

    Start enhancing patient outcomes and practice efficiency with a seamless Chronic Care Management program today.
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    • Streamlined Patient Enrollment
    • Proactive Monitoring & Coordination
    • Simplified Billing & Reimbursement

    Enhancing Your Practice’s Capacity & Efficiency

    With MoonMD, you’re not just getting a service—you’re gaining a trusted partner who works hand-in-hand with your practice. We’re here to support you with:

    Timely Services & Compliance

    Our automated tools ensure timely service delivery and seamless compliance, allowing you to focus on improving care without worrying about regulatory hurdles.

    Improve Patient Engagement

    By keeping patients engaged between visits, our solution boosts adherence and supports healthier outcomes through personalized care and ongoing communication.

    Extend Your Practice’s Reach

    MoonMD expands your practice’s reach by providing proactive care coordination and ongoing support that improve patient outcomes when it matters most.
    • How it Works

    MoonMD is all-in-one platform

    Streamlined Patient Enrollment

    Our system seamlessly connects with your existing EHR, making it simple to identify and enroll patients managing multiple chronic conditions.

    Proactive Monitoring & Coordination

    Our platform equips healthcare providers with advanced tools to continuously track patient health data and deliver comprehensive, coordinated care.

    Simplified Billing & Reimbusement

    Our platform automatically records clinical time and activities, providing precise, compliant documentation for effortless reimbursement. This allows you to expand care delivery without the burden of additional administrative work.

    Seamless Integration, Effortless Workflow

    MoonMD integrates smoothly with your existing systems, connecting effortlessly with your EHR and practice management tools—allowing you to add Chronic Care Management without interrupting your daily operations.

    • Our platform offers comprehensive, disease-specific care management templates for intake and follow-up, empowering health coaches to dedicate more time to patient care and education, reducing administrative tasks and streamlining workflows for maximum efficiency.
    • Whether managing one chronic condition or multiple, our platform adapts to your needs, ensuring your team stays connected with patients and monitors their health changes for continuous, personalized care.
    • We ensure seamless onboarding by verifying patient benefits on the same day of referral, completing patient enrollment within 24-48 hours, and enabling new providers to go live within just two weeks. Our efficient process allows you to focus on delivering care while we handle the details.
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    • CPT Codes

    Chronic Care Management CPT Codes

    $62.16

    AVERAGE MEDICARE RATES

    Notes

    Clinical Staff / Initial 20 minutes

    $47.04

    AVERAGE MEDICARE RATES

    Notes

    Clinical Staff / Initial 20 minutes

    $83.66

    AVERAGE MEDICARE RATES

    Notes

    Physician / Initial 30 minutes

    $59.47

    AVERAGE MEDICARE RATES

    Notes

    Physician / Each additional 30 minutes

    $60.49

    $45.93

    $83.18

    • FAQs

    Frequently Asked Questions

    Your Questions, Answered: Everything You Need to Know About Chronic Care Management

    Per your care focus, MoonMD assists in determining patient eligibility. General guidelines include:

    • Patients who qualify for CCM must have been managing two or more chronic conditions for at least 12 months.
    • CCM program members should be established patients who have previously received an evaluation and management service, either in person or via telehealth.
    • Patients cannot be enrolled in another CCM program simultaneously.
    • Nursing home patients are eligible for CCM participation.
       
    • Chronic conditions are
      Diabetes, Hypertention, Heath failure, Chronic pain, Obesity, Thyroid disease, Depression/Anxiety and many more
    • Many patients have no out-of-pocket costs.
    • Depending on their insurance plan, some may have a small financial responsibility, such as a copay.

    • MoonMD will reach out to patients with a copay estimate for approval before completing their enrollment in the program.

    • Patients can only participate in one CCM program with a single provider at a time.
    • However, those enrolled in CCM may also join an RPM or RTM program through MoonMD. This combined approach can enhance outcomes for patients with comorbidities, with each service billed separately under different CPT codes.

    • CCM services cannot be billed for the same patient more than once within the same month.

    Very! Our expert clinical monitoring staff members become a trusted coach. We also communicate with patients using their preferred channel, including phone, SMS, in-app messaging, and/or telehealth.

    There’s no ongoing obligation for providers. MoonMD also delivers a detailed monthly report directly to your EMR.

    Providers are responsible for submitting their reimbursement reports. Most of our clients prefer to manage billing themselves using the monthly summary reports provided by MoonMD. Full revenue cycle support is also available upon request.
    All reimbursements are paid directly to the provider.

    Medicare and most private insurance companies cover CCM.

    No, CCM is not encounter-based. With MoonMD handling patient monitoring and engagement, your office staff are not required to contact patients each month for billing purposes.

    Your patients’ data is fully protected with MoonMD. We are HIPAA-compliant and follow all privacy and security regulations for the proper use, disclosure, and safeguarding of patient information.

    MoonMD can get your program up and running in as little as two weeks. Our streamlined onboarding process requires only 2–3 hours of training time for your staff.

    • Referring patients is quick and simple—just a few clicks when integrated with your EMR. If your staff uses the MoonMD platform for referrals, the process takes about a minute.

    • MoonMD verifies insurance, and patients typically begin the program within 24–48 hours after referral.

    MoonMD is designed to scale effortlessly. Our platform can manage large volumes of data with no limit on the number of patients you can enroll.

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