The Complete Guide to Chronic Care ManagementHow to improve patient care, while generating new, recurring revenue.

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WHITE PAPER | The Complete Guide to Chronic Care Management

Seven of the top 10 causes of death in 2010 were chronic diseases1. The elderly are more likely to have chronic conditions with over 2/3 of Medicare beneficiaries having 2+ chronic conditions2.

In fact 93% of Medicare dollars spent are on patients with 2 or more chronic conditions2. These chronically ill patients have the highest hospitalization rate, the highest readmissions rate, are the highest utilizers of home health services – the list goes on.

As the number of conditions increase, so do the number of specialists and other providers treating these patients. In fact, 55% of chronically ill patients see 3+ physicians with 11% seeing over 6+ patients3.

Coordinating efforts between various members of the care teams becomes a challenge—poor handoffs can result in redundancy in medications, unclear instructions, fragmented data, and general confusion.

% of Total Medicare Spending ($587B in 2014) Number of Physicians Utilized (% of Patients) Figure 1: Figure 2:

THE PROBLEM

46%

28%

19%

7%

Number of Chronic Condtions

0-1 2-3 4-5 6+

23%

26%

16%

15%

11%

3%

6%

3 Physicians

4 Physicians

5 Physicians

6+ Physicians

0 Physicians

1 Physicians

2 Physicians

Care coordination, or facilitating the patients' care activities between encounters (such as office visits), is a critical part of managing the increasingly complex handoffs that occur while delivering care for chronically ill patients.

Care coordination is an evidence-based practice that has been shown to significantly improve clinical outcomes in both a primary care and acute care setting. A 9-month pilot by the American Academy of Family Physicians (AAFP) showed that telephonic nursing support improved clinical quality across 15 different HEDIS measures4.

THE SOLUTION

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WHITE PAPER | The Complete Guide to Chronic Care Management

The Center for Medicare and Medicaid Services (CMS) decided to use care coordination to help improve outcomes and reduce cost for their chronically ill patients – on January 1st, 2015 CMS introduced the new Chronic Care Management (CCM) program, for the first time reimbursing for non-face-to-face, telephonic care.

Pilot Results Versus National Best Practices

Category

Diabetes

Diabetes

Diabetes

Diabetes

Diabetes

Diabetes

CAD

CAD

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

*Commercial 2012 HEDIS 90th Percentile Targets

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Measure

A1C screening

A1C < 7.0%

LDL Screening

LDL < 100

Nephropathy Screening

Eye exams

LDL screening

LDL < 100

Colon cancer screening

Breast cancer screening

Cervical cancer screening

Osteoporosis screening

Pneumovax

Flu vaccine

Tobacco counseling

Pilot Baseline (December 2001)

88%

49%

85%

54%

89%

34%

84%

59%

67%

74%

41%

82%

78%

54%

55%

95.9%

55.1%

91.9%

58.9%

94.8%

70.3%

92.4%

66.1%

72.1%

78.0%

46.8%

88.1%

85.8%

65.3%

78.4%

93%

n/a

89%

n/a

88%

74%

92%

n/a

70%

76%

82%

82%

82%

61%

84%

Pilot Performance (September 2012)

HEDIS National Best Practice*

Table 1:

CPT 99490: Chronic Care Management

99490 reimburses physicians for the following:

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

Patient has multiple (two or more) chronic conditions expected to last at least 12 months, or until death

Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

Comprehensive care plan established, implemented, revised, or monitored

Unlocking the Revenue Potential of 99490Practices can earn $40.82/month2 providing CCM services for qualified patients, which translates to more than $240K per year with 500 enrolled patients.

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The full scope of service and billing requirements for CCM contains over 10 items, but the key requirements for launching a successfully CCM program are listed below:

ELIGIBILITY AND ENROLLMENT REQUIREMENTS

Provider Eligibility

Providers eligible to bill 99490 for their patients include:

Although the concept of CCM most closely aligns with primary care and lays the foundation for a Patient Centered Medical Home (PCMH), there are no restrictions on what specialties can bill for CCM. This means that specialists in additional to primary care physicians and family medicine practitioners can bill for 99490 as long as they meet the CCM requirements.

The one caveat to provider eligibility is that only a single practitioner may be paid for CCM in a given calendar month. Even if a patient is seeing multiple physicians (both a primary care physician as well as numerous specialists), only one of the patient’s physician can enroll the patient in CCM and bill for that patient.

Physicians (MD,DO)

Physician Assistants

Nurse Practitioners

Clinical Nurse Specialists

Certified Nurse Midwives

Patient Eligibility

Patients need to have two or more “chronic” conditions. A chronic condition can be defined as a condition that:

There is no strict list of qualifying conditions – a condition just has to meet the above two criteria. The below CMS chronic condition list is a starting point for qualifying conditions:

Is expected to last at least 12 months, or until the death of the patient

Places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

CMS Chronic Conditions

Acquired Hypothyroidism

Chronic Kidney Disease

Acute Myocardial Infarction

Chronic Obstructive Pulmonary Disease

Alzheimer's Disease

Depression

Anemia

Diabetes

Glaucoma

Asthma

Heart Failure

Atrial Fibrillation

Hip / Pelvic Fracture

Benign Prostatic Hyperplasia

Hyperlipidemia

Cancer, Colorectal

Hypertension

Cancer, Endometrial

Ischemic Heart Disease

Cancer, Breast

Osteoporosis

Cancer, Lung

Rheumatoid Arthritis / Osteoarthritis

Cancer, Prostate

Stroke / Transient Ischemic Attack

Cataract

Alzheimer's Disease, Related Disorders, or Senile Dementia

Table 2:

This list is non-exhaustive—even conditions such as Obesity may qualify if they meet the two criteria.

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Enrollment

There are two main components to the enrollment process of a new patient; a face-to-face encounter with the patient and the signing of the consent form during that face to face visit.

Face-to-Face Initiation of CCM

CMS has explicitly mentioned that the following face-to-face visits are acceptable to initiate CCM services for a patient.

Annual Wellness Visit (AWV)

Initial Preventive Physical Examination (IPPE)

Comprehensive E&M

Transitional Care Management

Consent Form

A written consent form agreeing to be enrolled in CCM has to be signed by the patient before 99490 can be billed. The consent form and explanation to the patient about the CCM program must include the following information:

Availability of CCM services

Authorization for the electronic communication of the patient's medical information with other treating providers

Existence of copay (if applicable)

Right to stop the CCM services at any time (effective at the end of the calendar month)

Only one practitioner can furnish and be paid for these services during a calendar month

TECHNOLOGY REQUIREMENTS

Electronic Care Plan

A critical component of billing for 99490 is the creation of a comprehensive, patient-centered care plan that is based on the physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient. This care plan will assist the provider in providing “whole-person” care for the patient. 99490 cannot be billed without the electronic care plan in place and this care plan should be kept up to date during subsequent billings. The three key requirements for the electronic care plan include:

Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record

Ensure the care plan is available electronically (24/7) to anyone within the practice providing the CCM service

Share the care plan electronically outside the practice as appropriate

Certified EHR

Any provider looking to participate in CCM has to have a certified EHR (e.g., ONC Certified) that satisfies the criteria of the EHR incentive program 2 years prior to the current year – this means in 2016 a provider would need a 2014 certified EHR.

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SERVICE REQUIREMENTS

Access to Care

Managing chronic conditions and their flare-ups does not always neatly coincide with business hours. For this reason, CMS has made it mandatory that patients participating in CCM receive “24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s health record to address his or her urgent chronic care needs.”

Access on the patient’s schedule, not the provider’s, is critical for avoiding unnecessarily ER utilization, such as ER use for urinary tract infections (UTIs). A study by the Henry Ford’s Vattikuti Urology Institute found that the average charge per patient for a UTI was approximately $2,000 per ER visit, $1,800 higher than the average cost of treatment in an outpatient clinic. The study concluded that giving patients greater access to primary care physicians could yield countrywide savings of nearly $4 billion a year on the basis of avoided UTI related ER visits alone5.

Other softer requirements around access to care include:

Billing

99490 cannot be billed simultaneously with a few other codes. These codes include:

If these exception codes are not being billed for a patient, CCM can be billed every month in perpetuity.

Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments

Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care (e.g., telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods)

Certain End-Stage Renal Disease services: 90951–90970

Home health care supervision: G0181

Hospice care supervision: G0182

Transitional Care Management: 99495–99496 (in the same calendar month)

Services

Coordinating care for a complex patient is a tremendous undertaking. According to CMS, services that should be provided during the 20 minutes of time include:

Systematic assessment of the patient’s medical, functional, and psychosocial needs

System-based approaches to ensure timely receipt of all recommended preventive care services

Medication reconciliation with review of adherence and potential interactions

Oversight of patient self-management of medications

Manage care transitions between and among health care providers and settings, including referrals to other providers

Coordinate care with home and community based clinical service providers

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Staffing

Personnel delivering the 20 minutes of service each month must meet the CPT definition of “clinical staff.” Front office workers and receptionist, who are not clinically credentialed, can NOT provide services that count toward the 20 minute threshold month. The CPT definition of clinical staff is staff who is:

This may and often does require practices to hire new staff to keep up with the growing demands of their CCM program.

“Allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.”

At CareHarmony, we are singular in focus—we seek to improve the patient experience and clinical outcomes by providing compassionate, whole-person care coordination services. Our high-tech, high-touch offering includes a turnkey Chronic Care Management solution designed to offer healthcare providers an easy, limited-risk first step into value-based care. We make launching CCM simple and risk free by bringing a unique blend of people, processes, and technology – all that is required of providers is to sign up patients! We serve a variety of organizations across the country, including physician practices, ACOs and IPAs.

Interested in Learning More?

For more information about CareHarmony, or chronic care management in general, please visit us online at www.care-harmony.com or give us a call at (629) 888-9201.

Footnotes:

1. Centers for Disease Control and Prevention. Death and Mortality. NCHS FastStats Web site. http://www.cdc.gov/nchs/fastats/deaths.htm. 2. Center for Medicare and Medicaid Services. Chronic Conditions Among Medicare Beneficiaries. 2012. 3. Gallup Serious Chronic Illness Survey, 2002. 4. The Benefits of Using Care Coordinators in Primary Care. American Academy of Family Physicians – December 2013. 5. Sammon, Jesse. ER Visits for UTIs Add Almost $4 Billion a Year. Vattikuti Urology Institute. May 2013.

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