Service · CCM
Chronic Care Management
Structured, ongoing support for patients with two or more chronic conditions.
Overview
What CCM looks like in practice
Chronic Care Management extends your practice's reach beyond the exam room. Patients managing multiple chronic conditions get a dedicated care team member who checks in monthly, reviews their care plan, coordinates with specialists, and helps close gaps before they become emergencies.
Spire's CCM team documents every interaction in a format that maps directly to your EHR and to CMS's time-based CCM requirements, so the clinical work and the billing paperwork happen together, not as two separate efforts.
For patients, it means a familiar voice checking in between visits. For your practice, it means better-managed populations and a new, sustainable revenue stream for work that's happening anyway.
How it works
Identify eligible patients
We help your team flag patients who qualify based on chronic condition count and complexity.
Build the care plan
A comprehensive care plan is created and shared with the patient and your practice.
Monthly outreach
Our care coordinators call patients monthly to review symptoms, medications, and goals.
Coordinate care
We follow up on referrals, labs, and specialist visits so nothing falls through the cracks.
Document & bill
Time-stamped notes are organized against CCM CPT codes for straightforward billing.
Who it's for
- Patients with two or more chronic conditions expected to last at least 12 months
- Practices looking to formalize the informal care coordination already happening by phone
- Care teams that want a single source of truth for non-visit patient touchpoints
Key benefits
- At least 20 minutes of clinical staff time per patient, per month, fully documented
- A live, shared care plan updated after every interaction
- Medication reconciliation and referral follow-up handled proactively
- Reduced no-shows and readmissions through consistent between-visit contact
Billing & compliance
Documentation is organized around the time thresholds required for CMS Chronic Care Management codes, including complex CCM tiers, so nothing needs to be reconstructed at claim time.