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Chronic Care Management (CCM)

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0-10 Practices are currently using this product across the following Specialties
  • Family Practice


Capabilities: Chronic Care Management (CCM), Care Plan Management

myDoctorsMedicalRecord (myDMR) is a cloud-based, end-to-end Chronic Care Management (CCM) service that streamlines workflow, enabling your staff to proactively improve the health outcomes of chronically-ill patients while increasing the revenue of your practice.

Using encrypted communications and clinical document repository, myDMR also empowers patients to grant other healthcare providers remote access to their clinical information, such as when travelling, after clinic hours or during a transition of care.

The myDMR service simplifies the Care Manager’s CCM workflow – from enrollment though to billing – and provides the following capabilities:

Program Eligibility

  • Automatically identify which patients are eligible for CCM
  • Track each patient’s enrollment status (enrolled, declined, etc.)

Care Coordination

  • Create, review and update a patient’s comprehensive care plan
    • patient demographics are auto populated from the EMR
  • Leverage built-in task management tools:
    • customize default tasks (available pre-loaded tasks include common CCM tasks and related HEDIS tasks)
    • create new tasks
    • set recurring reminders for routine tasks
  • Automatically log the time spent on non-face-to-face tasks
    • Manually capture ad-hoc tasks
  • View high-level info in patient dashboard
    • Quickly identify patients needing added care in current month
  • Customize user functions based on role (care manager, billing provider, etc.)


  • With one click, submit a patient’s monthly billing report to athenahealth
  • Retain records for potential CMS audit

After Hours Support

  • Print a wallet card at the clinic for CCM-enrolled patients
    • Wallet card provides directions for a clinician (i.e. in Emergency Department) to view the patient’s summary care record (CCD) in myDMR

Note: Patient has pre-established their consent for this purpose of use (US Pat. 10,902,382/EU Pat. 2729913)

Patient Engagement

  • Empower patients with online access to their care plan and summary of care record (CCD)

Chronic Care Management CPT Codes Supported

  • Non-complex CCM (99490, 99439)
  • Complex CCM (99487, 99489)
  • CCM services provided personally by a physician or other qualified healthcare professional (99491)

Other Codes to be Supported

  • Transitional Care Management (TCM) (99495, 99496)
  • Behavioral Health Integration (BHI) (99484)
  • Remote Physiologic Monitoring (RPM) (99453, 99454, 99091, 99457, 99458)

Want a demo? Reach out to us at info@mydoctorsmedicalrecord.com.

The information contained on the Marketplace website is provided by third party MDP Partners related to their services provided through the MDP program. athenahealth does not review the information provided on the Marketplace, and is not responsible for the accuracy of any content provided on the Marketplace.