Chronic Care Management Diagnosis List: Understanding Qualifying Conditions

Chronic Care Management (CCM) is a vital program designed to empower Medicare patients in managing their chronic health conditions effectively. By connecting patients with dedicated care coordinators, CCM facilitates better understanding of their conditions, promotes proactive healthcare management, and improves overall health outcomes. Care coordinators play a crucial role in this process, offering monthly support to help patients define health objectives, schedule necessary medical appointments, manage medication refills, and access valuable community resources. However, a lack of familiarity with CCM might lead some healthcare practices to underestimate the breadth of conditions that qualify patients for this beneficial program.

To clarify eligibility and highlight the potential of CCM, we present a comprehensive list of chronic conditions that commonly qualify patients for enrollment. While this list serves as a guide, it is essential to remember that the final determination of a patient’s suitability for CCM rests with their healthcare provider, who can best assess individual needs and circumstances.

Common Chronic Conditions Qualifying for CCM

Medicare’s Chronic Care Management program is designed for individuals grappling with at least two chronic conditions expected to persist for a minimum of 12 months. These conditions should also pose a significant risk of acute exacerbation or a progressive decline in functional abilities, underscoring the necessity for ongoing and coordinated care.

Below is an extensive list of conditions frequently encountered in CCM-eligible patients. It is important to note that while these conditions often meet the criteria for CCM, the ultimate decision regarding program enrollment is a clinical one, made by the patient’s healthcare provider.

Cardiovascular and Blood Conditions

Conditions affecting the heart and blood vessels are frequently seen among CCM patients. These encompass a range of disorders that require continuous monitoring and management to prevent severe health complications. Common cardiovascular conditions include:

Hypertension: Also known as high blood pressure, it is a leading risk factor for heart disease and stroke.
Ischemic heart disease: Characterized by reduced blood supply to the heart, often due to narrowed arteries.
Congestive heart failure: A condition where the heart cannot pump blood effectively to meet the body’s needs.
Anemia: A deficiency in red blood cells or hemoglobin, leading to reduced oxygen flow in the body.
Atrial fibrillation: An irregular and often rapid heart rhythm that can increase the risk of stroke.
Hyperlipidemia: High levels of lipids (fats) in the blood, including cholesterol and triglycerides.
Diabetes: A metabolic disorder characterized by high blood sugar levels.
Coronary artery disease: A narrowing or blockage of the coronary arteries, which supply blood to the heart muscle.
Sick sinus syndrome: A group of heart rhythm disorders caused by malfunction of the heart’s natural pacemaker.
Angina: Chest pain or discomfort caused by reduced blood flow to the heart muscle.
Sickle-cell disease: An inherited blood disorder causing red blood cells to be abnormally shaped.
Peripheral vascular disease (PVD): Conditions affecting blood vessels outside of the heart and brain, commonly in the legs and feet.

Cancer and Oncology Conditions

Chronic cancers necessitate ongoing care and management, making them frequently qualifying conditions for CCM. The program can provide crucial support in managing treatment side effects and improving quality of life for patients with:

Breast cancer: Cancer that forms in the cells of the breasts.
Lung cancer: Cancer that starts in the lungs and is the leading cause of cancer death worldwide.
Prostate cancer: Cancer that occurs in the prostate, a small gland in men.
Colorectal cancer: Cancer that begins in the colon or rectum.
Leukemias and lymphomas: Cancers of the blood and lymphatic system.

Bone, Joint or Muscle Conditions

Conditions impacting mobility and quality of life due to bone, joint, or muscle issues can significantly benefit from the coordinated care provided by CCM. Examples include:

Osteoporosis: A condition characterized by weakened bones, increasing the risk of fractures.
Rheumatoid arthritis/osteoarthritis: Chronic joint disorders causing pain, stiffness, and inflammation.

Eye Conditions

Vision impairment from chronic eye conditions can significantly impact daily living. CCM offers support in managing these conditions and preventing further vision loss:

Cataracts: Clouding of the natural lens of the eye, causing blurred vision.
Glaucoma: A group of eye conditions that damage the optic nerve, often due to increased pressure inside the eye.
Diabetic retinopathy: Damage to the blood vessels in the retina caused by diabetes.
Age-related macular degeneration: An eye disease that can blur central vision and is a leading cause of vision loss in older adults.

Further Chronic Conditions Eligible for CCM

Beyond the categories above, numerous other chronic conditions across various body systems qualify for Chronic Care Management, ensuring comprehensive support for patients with diverse healthcare needs.

Urology and Nephrology Conditions

Conditions affecting the urinary system and kidneys require careful management to maintain kidney function and overall health. These include:

Chronic kidney disease: Progressive loss of kidney function over time.
Benign prostatic hyperplasia: Enlargement of the prostate gland, common in older men.
Kidney cysts: Fluid-filled sacs that can form in the kidneys.

Gastroenterological Conditions

Chronic digestive conditions can significantly impact nutrition and quality of life. CCM can aid in managing symptoms and improving digestive health for conditions like:

Irritable bowel syndrome: A common disorder affecting the large intestine, causing cramping, abdominal pain, bloating, gas, diarrhea, and constipation.
Crohn’s disease: A chronic inflammatory bowel disease that affects the lining of the digestive tract.
Ulcerative colitis: Another type of inflammatory bowel disease that causes inflammation and ulcers in the lining of the large intestine and rectum.

Ear, Nose, and Throat Conditions

ENT conditions, while sometimes overlooked, can have a chronic impact on well-being. CCM can support patients dealing with:

Sleep apnea: A sleep disorder in which breathing repeatedly stops and starts.
Tinnitus: Perceiving ringing or other noises in the ears when no external sound is present.
Vertigo: A sensation of spinning dizziness.
Conductive or sensorineural hearing loss: Different types of hearing impairment due to problems in the outer/middle ear or inner ear/auditory nerve.

Mental Health and Neurological Conditions

Neurological and mental health conditions often require long-term, coordinated care. CCM plays a vital role in supporting individuals with a wide range of disorders, including:

ADHD: Attention-deficit/hyperactivity disorder, a neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity.
Alzheimer’s Disease and dementia: Progressive brain disorders that cause memory loss and cognitive decline.
Post-traumatic stress disorder (PTSD): A mental health condition triggered by experiencing or witnessing a terrifying event.
Anxiety disorders: Conditions characterized by excessive worry, fear, and nervousness.
Depressive disorders: Mood disorders causing persistent sadness and loss of interest.
Autism: A developmental disorder that affects communication and behavior.
Schizophrenia and other psychotic disorders: Severe mental disorders that cause abnormal thinking and perceptions.
Bipolar disorder: A mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks.
Traumatic brain injury and nonpsychotic mental disorders due to brain damage: Mental health issues arising from brain injuries.
Migraine and chronic headaches: Recurring severe headaches that can be debilitating.
Cerebral palsy: A group of disorders affecting movement and posture, caused by brain damage during development.
Epilepsy: A neurological disorder characterized by recurrent seizures.
Parkinson’s: A progressive nervous system disorder that affects movement.

Learn more: How to Manage Chronic Mental Illness with Chronic Care Management

Respiratory Conditions

Chronic respiratory conditions require ongoing management to improve breathing and quality of life. CCM offers support for patients with:

Asthma: A chronic lung disease that inflames and narrows the airways.
Chronic obstructive pulmonary disease (COPD): A group of lung diseases that block airflow and make it difficult to breathe, often associated with smoking.
Emphysema: A COPD condition that damages the air sacs (alveoli) in the lungs.
Cystic fibrosis: An inherited disorder that damages the lungs and digestive system.

Substance Use Disorders

Substance dependence can significantly impact health and well-being. CCM can provide support for individuals struggling with:

Alcohol dependence disorders: A chronic relapsing brain disease characterized by compulsive alcohol seeking and use.
Opioid dependence disorders: Dependence on opioid drugs, leading to significant health and social problems.
Nicotine dependence: Addiction to nicotine, commonly through smoking.
Other drug use disorders: Dependence on other illicit or prescription drugs.

Autoimmune Conditions

Autoimmune conditions, where the body’s immune system attacks healthy cells, often require complex and ongoing management. CCM can assist patients with:

Human immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV/AIDS): A viral infection that attacks the immune system.
Viral hepatitis: Inflammation of the liver caused by a viral infection.
Multiple sclerosis: A chronic, autoimmune disease that affects the brain and spinal cord.
Hypothyroidism: Underactive thyroid gland, leading to insufficient thyroid hormone production.

Bone, Joint, Spine or Muscle Conditions

Conditions affecting the musculoskeletal system can significantly impact mobility and daily function. CCM provides support for patients with:

Spinal cord injury: Damage to the spinal cord that can cause paralysis and other disabilities.
Spina bifida: A birth defect where the spinal cord doesn’t close completely.
Muscular dystrophy: A group of genetic diseases that cause progressive weakness and loss of muscle mass.
Fibromyalgia: A widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
Chronic pain: Persistent pain that lasts for three months or longer.

Other Disabling Conditions

Various other conditions can be debilitating and qualify for CCM due to their impact on essential life functions. These include:

Developmental and learning disabilities: Conditions that affect cognitive and physical development.
Intellectual disabilities and related conditions: Limitations in intellectual functioning and adaptive behavior.
Liver disease, cirrhosis and other liver conditions: Conditions affecting the liver’s function and structure.
Blindness and visual impairment: Severe loss of vision.
Meniere’s disease and other sources of hearing loss: Inner ear disorder causing vertigo, tinnitus, and hearing loss.
Obesity: Excessive body weight that increases the risk of various health problems.

Practices partnering with ChartSpan for CCM benefit from a streamlined process of patient identification. ChartSpan assists in compiling a comprehensive list of patients eligible for CCM based on CMS guidelines. Healthcare providers then review this list to determine the most suitable candidates for program enrollment, ensuring that CCM services are directed to those who will benefit most.

Benefits of CCM for Eligible Patients

Once a patient is identified as eligible for Chronic Care Management and chooses to enroll, they gain access to a robust support system. This includes at least 20 minutes of monthly care coordination by a dedicated care manager, operating under the guidance of a qualified healthcare provider. These interactions are typically conducted remotely, unless an in-person visit for CCM services is clinically necessary. Crucially, patients also have 24/7 access to a care team member for urgent medical concerns, providing peace of mind and immediate support when needed.

The care coordinator collaborates with the patient to develop a personalized, comprehensive care plan, readily accessible to the patient at any time. Monthly follow-up calls are a cornerstone of CCM, during which the care coordinator monitors progress towards health goals, conducts care gap assessments to ensure all healthcare needs are addressed, and assists with practicalities such as appointment scheduling and prescription refills. Furthermore, CCM extends beyond medical care by connecting patients with vital community resources, addressing social determinants of health by providing access to support for food, housing, social engagement, and emotional well-being.

Leverage Chronic Care Management to Enhance Patient Care

By utilizing a detailed chronic conditions list, aligned with CMS guidelines, and with the support of experienced partners like ChartSpan, healthcare practices can effectively identify and enroll eligible patients in Chronic Care Management programs. The extensive range of qualifying conditions underscores the broad applicability of CCM and its potential to significantly improve patient outcomes. ChartSpan’s CCM solution streamlines the identification and enrollment process, ensuring that eligible patients are informed and given the opportunity to participate. By entrusting administrative tasks and remote care coordination to ChartSpan, practice staff can concentrate on delivering in-person care, optimizing efficiency and enhancing the overall patient experience. To delve deeper into CCM, explore our comprehensive guide to frequently asked questions about CCM and compliance.

Subscribe for More Insights

Get valuable resources delivered straight to your inbox.

“*” indicates required fields