PBSMD Chronic Care Management Services

PBSMD offers a turn-key solution for practices, allowing you to receive your CCM revenue. The program provides a Call Center of trained and certified medical assistants who:

Conduct chronic care phone calls with your patients each month

Document the calls appropriately and securely in your EHR


What do I need to do


  • 20 minutes of non face-to-face chronic care services
  • Medicare patients with 2+ chronic conditions will be eligible
  • Only one providing physician may bill
  • Services can be billed every month
  • Use a certified EHR – MU I or MU II (if you don’t currently have one, don’t worry – we do!)
  • Ensure beneficiary 24/7 access to care plan via a Patient Portal (we have one of those, too!)
  • Facilitate transitions of care or follow-up after ER or hospitalization
  • Coordinate care and manage referrals to other physicians
  • Share data electronically with other providers

Patient Panel Size 1 3,279
% of Panel on Medicare 1 21.85%
Medicare Patients 716
% of Medicare patients CCM Eligible 2 68.6%
% of CCM Eligible Patients 491
Annual Billing for CCM Patient $484.68
Annual CCM Revenue Potential $250,999


1 Per the MGMA Cost Survey for Single Specialty Practices: 2013 Report Based on 2012 Data specific to the specialty of family medicine. Includes Medicare A/B and Medicare Advantage

2 CMS.gov - County Level Multiple Chronic Conditions (MCC) Table: 2012 Prevalence, National Average

* Reimbursement amount from the CY 2015 Physician Fee Service Final Rule; assumes 100% of unique patients are covered by Medicare A/B. Medicare Advantage reimbursement may vary