Chronic Care Management That Strengthens Patient Relationships — and Your Practice
At Axial Patient Care, we help you deliver proactive, high-quality care for your chronically ill patients while unlocking a steady, compliant revenue stream for your practice.
Why Chronic Care Management Matters
More Patients Than Ever Are Managing Chronic Conditions — and They Need More Than Office Visits
Patients with multiple chronic conditions require ongoing coordination:
- Medication refills.
- Specialist referrals.
- Diagnostic testing reminders.
- Health coaching.
Most practices already provide much of this support — but without structured programs, these efforts often go unreimbursed and unnoticed.
Chronic Care Management (CCM) changes that.
With Axial, you can give your patients the ongoing, personalized support they deserve — and get paid for the care you're already providing.
How Our Chronic Care Management Program Works
A Seamless Extension of Your Practice
- Patient Enrollment: We work with your practice to identify eligible patients with two or more chronic conditions.
- Monthly Clinical Outreach: Our experienced nurses contact patients every month to review medications, coordinate care, arrange diagnostic testing, and address emerging health needs.
- Care Coordination: We handle tasks that reduce the burden on your office, including scheduling reminders, referral assistance, medication management, and health coaching.
- Detailed Documentation: Axial provides thorough, compliant reporting to support your billing efforts and ensure audit readiness.
You stay in control
— we simply extend your ability to deliver consistent, high-quality care between office visits.
Benefits to Your Practice
The Value of Chronic Care Management
New, Reliable Revenue Stream
Generate additional income for every eligible patient enrolled.
Reduced Administrative Burden
Decrease medication refill calls, appointment scheduling stress, and patient follow-up load on your staff.
Improved Patient Outcomes
Early interventions reduce hospitalizations, improve medication adherence, and enhance patient satisfaction.
Enhanced Practice Reputation
Demonstrate commitment to high-quality, patient-centered care.
Why Partner with Axial Patient Care?
Expert Care. Trusted Partnership.
At Axial Patient Care, patient well-being comes first.
Our team serves as a compassionate, professional extension of your office — treating your patients with the same respect and attentiveness you would.
We make the process simple, compliant, and revenue-positive for your practice, while keeping patients engaged and connected.
- You get better clinical outcomes.
- Patients get better support.
- Your practice grows stronger.
Chronic Care Management (CCM) – FAQ
1. What qualifies a patient for Chronic Care Management?
Patients are eligible if they have two or more chronic conditions expected to last at least 12 months (or until death) and that place them at significant risk of functional decline, hospitalization, or death.
2. Who performs the monthly patient outreach?
Axial Patient Care’s licensed clinical team handles monthly outreach, coordination of care, medication reviews, appointment reminders, and patient education — all documented for compliance and billing.
3. Do we have to do anything in the office to get started?
Very little. Axial handles nearly everything — from patient onboarding to monthly calls and documentation. Your practice simply needs to approve eligible patients and review our monthly reports for billing.
4. How is CCM reimbursed?
CCM is reimbursed by Medicare and most Medicare Advantage plans using CPT Code 99490 and related codes. Reimbursement ranges from $40–$120+ per patient per month, depending on time spent and complexity.
5. Can we bill for CCM and other care management services at the same time?
Some care management codes can be billed in the same month if services are distinct, but CCM cannot be billed with RPM for the same patient in the same month. Axial helps ensure compliant billing strategies.
Confident Start
Bring Chronic Care Management to Your Practice with Confidence
Let's discuss how easy it can be to get started.