Managing Chronic Care Management

By Susan D’Agostino, RN

Before we can discuss managing Chronic Care Management (CCM), let’s talk about what CCM is. CCM was initiated in 2015 by CMS for Medicare beneficiaries.  Organizations were able to bill for chronic care management patients starting on January 1, 2015. Those organizations providing non-face-to-face time for Medicare patients who have 2 or more chronic conditions were given the opportunity to use CPT code 99490.  What did that mean exactly?  In addition to office visits and other face-to-face encounters (billed separately) non-face-to-face time services that include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients can be reimbursed. For 2017, not only can a clinic continue to use CPT 99490, but there are now 2 more codes available to use depending on the complexity of the patient.  

CMS does not provide a full exclusive list of chronic conditions to follow but has provided some guidelines on what qualifies as a chronic condition.  The below graph shows the top conditions that are targeted by CCM programs.                                                                                      


As you can see,  several conditions are considered lifestyle diseases.  Diet and lifestyle are major factors that influence susceptibility to many diseases.  The first real step in managing chronic conditions is helping patients in making choices to prevent them from occurring in the first place.

Chronic Care Management not only impacts patient outcomes by improving the quality of care but also provides what can be a significant return on investment for organizations that implement the program.  At approximately $43.00 per month per patient (or more for a complex patient), depending on your organizations qualifying patient population the reimbursement could be quite substantial.

Like most clinics, yours is probably already doing the majority of tasks needed to implement the CCM program but just need to implement a formalized program.  It may be helpful to have a CCM coordinator placed in charge of the program.  A lead nurse or medical assistant usually work well in this role. 

Once you have your population identified, getting consent and putting a documented comprehensive care plan in place are the first steps.  Documentation of the 20 minutes of non-face-to-face time is key.  Some tasks that satisfy the requirements include:

  • Care coordination/referrals
  • Health coaching by telephone or secure email
  • Medication Management including renewing medications, monitoring tapering schedules, a phone call to check on side effects of anew med
  • Education provided to the patient or caregiver
  • Following up with patients with lab or imaging test results

For further information on Chronic Care Management requirements as well as Transitional Care Management, check out CMS.GOV

Using a certified EHR is a must.  Having the discrete data available allows applications like PrecisionBI the ability to search for and create the reports and dashboards that will let you know that the care you are providing the patients that are enrolled in your CCM program are meeting the monthly requirements needed for reimbursement. In addition, Precision BI’s partnership with VitreosHealth will allow organizations the ability to identify patients that are not only high risk now, but will be within the next 12-18 months. 

PrecisionBI is web-based and easy to use, even the most non-technical users can access the information needed to determine if goals are being met. To learn more on how PrecisionBI can help please contact us for a demonstration or to answer any questions.