Care Coordination for Patients with Multiple Chronic Conditions
Chronic Care Management (CCM) is a set of coordinated services provided outside of the regular office visit. These services are provided to Medicare patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, that place the patient at significant risk of death or functional decline. The first chronic care management code was added in 2015 and an additional three codes were added in 2017 to allow for additional billing for complex patients. These services include phone and electronic communication, accessibility and the establishment of electronic care plans. Patients in a long-term or skilled nursing facility are not eligible.
Who Can Provide Chronic Care Management Services?
Codes for this service are included in the Medicare Physician Fee Schedule. Physicians and the following health care professionals can bill for chronic care management services: Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse Midwives. Additionally, many key components may be conducted by a pharmacist or primary care physician in a clinical staff capacity. Pharmacy staff and office managers can also provide support for non-clinical components. Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals can also bill for chronic care management services. Only one practitioner per patient may be paid for these services for a given calendar month.
Five Components of Chronic Care Management
Prior to providing chronic care management services, the patient must provide consent. Chronic care management may be initiated by phone or in-person for patients who have had a visit with the Qualified Healthcare Provider (QHP) in the past 12 months. Otherwise the service must be initiated during an Annual Wellness Visit. Consent may be obtained verbally or in writing and must be documented within the patient’s medical record.
- Recording structured data in the patient’s health record
- Medication allergies in a certified EHR
- Maintaining a comprehensive care plan for each patient
- Includes problem list, expected outcomes/prognosis, treatment goals, medication management, and community/social services ordered
- Identify how services not provided within the practice will be coordinated
- Provide patient and caregiver with copy
- Maintain electronic record
- Providing 24/7 access to care
- 24-hour pharmacies may fulfill this requirement, assisting the QHP with meeting this key component
- Ensure continuity of care
- Provide enhanced opportunities such as telephone, email, secure portal
- Comprehensive care management
- Care management services including assessment of medical, functional, and psychosocial needs
- Medication Reconciliation and oversight of medication self-management
- Care coordination with other providers and community services
- Transitional care management
- Manage transitions, discharge, referrals
- Exchange continuity of care documents with other providers
- Patient referrals
- Recording structured data in the patient’s health record
- Medicare will reimburse Qualified Healthcare Providers (QHPs) for providing chronic care management services to beneficiaries with two or more chronic conditions (approximately two-thirds of Medicare beneficiaries), expected to last 12 months, and placing patient at serious risk. Chronic care management differs from complex chronic care management is additional time spent with a high-risk patient.
- Pharmacists cannot bill directly, only QHPs:
- QHPs include the following: physician, nurse practitioner, physician assistant, clinical nurse specialist, certified nurse midwives
- Pharmacists or other staff in a clinical support role will need a contractual relationship required to facilitate payment and patient care
- Clinical support staff may be directly employed, independent contractor, or leased employment
- A pharmacist or other support staff may be supported with a Collaborative Drug Therapy Management agreement.
- Pharmacists may support as clinical staff; pharmacy staff may support as non-clinical staff. Pharmacists should check their state scope of practice authority for delivering various aspects of chronic care management both as clinical staff and auxiliary personnel. Clinical staff may provide services under general supervision from the physician.
Note: reimbursement varies as it is specific to locality. These totals represent non-facility rates.
- CPT 99490: original chronic care management code. Allows eligible practitioners and suppliers to bill for at least 20 minutes of non-face-to-face clinical staff time each month to coordinate care for patients who have two or more chronic conditions. 20 Minutes, $42 average reimbursement
- CPT 99487: for complex chronic care management that requires substantial revision of a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time. 60 Minutes, $93 average reimbursement
- CPT 99489: a complex chronic care management add-on code for each additional 30 minutes of clinical staff time. 30 Minutes, $47 average reimbursement
- HCPCS G0506: an add-on code to the chronic care management initiating visit for providing a comprehensive assessment and care planning to patients. One-time, $63 average reimbursement. This code cannot be billed by RHCs or FQHCs
- The date of service may be the date that the 20-minute minimum was met or any subsequent date that month
- Place of service must be the location the billing provider would ordinarily provide face-to-face services to the patient.
- Services billed “incident-to” must be billed under the supervising provider
- Assuming an average panel of 550 Medicare beneficiaries and the 2017 national average payment rates, revenue from billing chronic care management could total $46,852 and complex chronic care management $37,255. This assumes Medicare Advantage and Medicare are reimbursing at the same rate.
- A pharmacist should consider a Business Agreement that outlines a productivity-based revenue, whereby the revenue generated is distributed based on which clinician is performing the majority of the billable services.
Electronic Health Record Requirements
- Version of certified electronic health record (EHR) that is acceptable under the EHR Incentive Programs as of December 31 of the calendar year preceding each Medicare PFS payment year. Must be used for structured recording of patient health and documentation of provision of care plan. Clinical summaries and documentation of consent does not require the use of certified EHR technology at this time.
- Pharmacist and other clinical support staff may document outside EHR and send securely if EHR platform cannot be shared across providers.
- Provider is not required to be a meaningful-user of the EHR.
- Consent must be documented within the electronic (EHR). Copayments do apply to this service, ensure the patient is aware of this.
- Tracking the 20 minutes of billable non-face-to-face time must be documented but there is not a specific method for tracking.
- After hours’ care (including 24/7 pharmacy) must be provided by a clinical partner with access to the care plan. This may be via a secure portal, hospital platform, web-based platform, Health Information Exchange, or EHR/EHR exchange.
- Services may be provided “incident-to” the designated clinician if the chronic care management services are provided by licensed clinical staff employed by the clinician or practice who are under the general, not necessarily the direct, supervision of the designated clinician. The normal “incident-to” documentation requirements apply. Click here to see Section 60 of Medicare Benefit Policy Manual, Chapter 15.
Steps to Establish a Program
- Identify and develop a relationship with a partner QHP.
- Develop a plan for reimbursement, ideally a Business Agreement.
- Identify eligible patients:
- Run EHR report of Medicare patients with 2 or more chronic conditions,
- Alongside clinician, review patients and identify those that would be a good fit for this service and
- Consider additional criteria such as specific diagnoses, especially for a new program.
- Assign a care team and define roles for QHP, Clinical Staff and Non-Clinical Staff
- Define a process and a schedule for delivery of chronic care management services including a:
- Timeline for enrollment/consent calls,
- Monthly goals for staff to reach the 20 minutes of billable non-face-to-face services and
- Ensure a method of communication between QHP, clinical, and non-clinical staff, including access to an EHR if possible.
- Inform patients and obtain consent.
- Create and document a Comprehensive Care Plan. Share with other providers and clinicians as appropriate. Provide patient with written and/or electronic copy
- Document time spent to include:
- Patient phone calls and emails,
- Coordination with other clinicians, community resources, caregivers, etc. and
- Prescription management/medication reconciliation.
Strengths, Weaknesses, Opportunities and Threats
- Do we have a strong relationship with a primary care provider?
- Patient mix – Medicare patients
- Expertise and capacity to fulfill requirements of CCM clinical staff role
- Services being provided that benefit the patient and primary care team, align with goals of CCM
- EHR access and use
- Documentation requirements
- Communication with provider
- Time, space to dedicate to this program
- Collaborative Practice Agreements
- Billing/reimbursement relationship with a primary care provider
- Increased revenue
- Training needs of pharmacist and staff, of primary care team
- Ability to demonstrate improved outcomes from current medication adherence work?
- State restrictions on pharmacist provider status
- Patient buy-in
- Billing and documentation requirements
The following codes cannot be billed during the same month as chronic care management (CPT 99490):
- Transition Care Management (TCM): CPT 99495 and 99496
- Home Healthcare Supervision: HCPCS G0181
- Hospice Care Supervision: HCPCS G9182
- Certain ESRD services: CPT 90951-90970
Only one clinician may bill for these services in a given month. The expectation is the physician providing the majority of the patient’s primary care will do so. Care must be “contact initiated”, meaning direct contact with the patient or direct contact between providers as a result of contact and/or results with/in the patient. In-person and group visits cannot count towards chronic care management.
Medicare Advantage plans are required to offer chronic care management services; however, some fulfill the service with their in-house care management. Confirm patient eligibility prior to providing service and billing.