Chronic Care Management
A patient has two or more chronic conditions expected to last at least 12 months, or until death.
Explore CCM →Ongoing care
CCM, PCM or APCM?
Match the care-management model to the patient’s needs and the practitioner’s role. These are not three interchangeable ways to bill the same work.
Three approaches to ongoing care.
Principal Care Management
One complex chronic condition is expected to last at least three months.
Explore PCM →Advanced Primary Care Management
The patient has an ongoing primary-care relationship with the practitioner who serves as the focal point for needed care.
Explore APCM →What changes in the operating model?
| Question | CCM | PCM | APCM |
|---|---|---|---|
| Care focus | Multiple qualifying chronic conditions | One complex, high-risk chronic condition | The ongoing primary-care relationship |
| Clinical anchor | Practitioner-directed comprehensive care plan | Practitioner managing the principal condition | Practitioner responsible for all primary care and serving as the continuing focal point |
| Time model | Documented qualifying time | Documented qualifying time | Monthly bundle, not a minimum-minute model |
| Important distinction | Coordinate across the comprehensive care plan | Maintain a disease-specific plan | Meet the practice-level capabilities, access and reporting requirements |
Where MySeema fits.
Across these models, our role is the agreed outreach, coordination, documentation and follow-through. The scope and qualified personnel must fit the program you select.
Compare alternative scenarios; do not add these estimates together for the same patient population.
Set the responsibilities before launch.
- Who owns the comprehensive or condition-specific care plan?
- Who handles consent, patient cost-sharing information and initiating visits?
- Who meets access, qualified-personnel and escalation requirements?
- Which current services would the selected model replace?
Sources reviewed October 5, 2026: CMS care-management guidance and CMS APCM requirements.