Chronic Care Management is a specific care management service that provides coverage for patients with two or more chronic conditions.
CCM services are usually completed by primary care providers, and principal care management services are put in place to primarily focus on specialists to have their own care managers. However, if a primary care provider is not billing for ccm services at times, a specialist can decide to bill for this service since only one provider is able to bill for ccm services.
What is the purpose of CCM?
Medicare holds CCM as a critical component of primary care for patients. CCM helps patients improve, maintain, or reverse their chronic condition and allows chronic care management patients to work with providers and their care team. CCM is a telehealth service done in between provider visits.
What is the benefit of CCM and PCM?
CCM and PCM services help the patient better understand their chronic care condition(s) and help better manage the disease. CCM Services are designed to catch issues early, direct the patient to the provider when needed, and avoid unneeded ER visits and hospital admissions or readmissions, which can cut the cost to provide care to patients and keep them healthy in their home.
What is General Care Management (GCM)?
GCM is billed primarily for chronic care management services furnished by rural health centers and federally qualified health centers. If you are a community health center, then CCM services would be billed instead of GCM services. Medicare’s GCM services are paid at a flat rate nationwide, and the requirement is to meet the full scope of services which includes all the services for chronic care management services to include integrated behavioral health services, along with the time requirement of a minimum of 20+ minutes spent per month. An integrated behavioral health code is not billed when this service is completed but is included as part of this CPT Code G0511.
What does chronic care management include?
Chronic Care Management includes a discussion with the patient to review a number of items once the comprehensive care plan is put in place with the patient. When providing CCM services all the chronic conditions need to be reviewed each month prior to billing the services to fulfill the full scope of services and the required time element needs to be met as well. Among some of the required elements of the scope of service to be discussed are as follows:
- Systematic assessment of medical, functional and psychosocial needs completed?
- Medication Allergies Reviewed and Updated
- OTC/Herbals Reviewed and updated
- Medications Reviewed, Updated, and Reconciled
- Drug interactions reviewed
- Medication Reconciliation
- Preventive services
- Transitional care management services
- Care Coordination services
What are examples of chronic care?
- Making sure CCM patients are reminded of their preventive services due such as their annual wellness exams, mammograms, colon rectal screening, influenza vaccine, etc. These reminders can be performed by either the physician or clinical staff.
- Working with CCM patients to discuss new eating habits needed since they have been newly diagnosed with a chronic condition or existing chronic condition
- Reviewing their readings from remote physiologic monitors i.e. glucometer, CGM, blood pressure monitor, oxygen meter etc. to make sure they are in range or alert the physician mid-level and staff if they are not in case a medication change may be needed
- Sharing information with CCM patients to help them stop smoking
- Making sure the specialist notes are all back in the chart for the provider to review prior to the patient coming in for their office visit
- Assisting with information sharing among providers by coordinating the chronic care program
- Medication reconciliation and update provider if there are changes or refills needed
- Reviewing any new herbals or OTCs the patient is taking and notifying the provider to confirm if there are any interactions with their existing medications
- Seeing if a patient needs any qualified medical equipment such as a wheelchair or walker
What is a CCM Eligible Chronic Condition?
According to CMS (Centers for Medicare and Medicaid Services), a chronic condition is a condition that places the patient at significant risk of death, acute exacerbation/ decompensation, or function decline. In order to bill for Medicare’s chronic care management service codes, the patient must have multiple chronic conditions, and the conditions are expected to last at least 12 months or until the death of the patient. Examples of CCM-eligible chronic conditions can be found on the Medicare Chronic Condition Data Warehouse.
New conditions are being added as CMS has elaborated on the definition of a chronic condition. Examples of chronic conditions are as follows:
- Alzheimer’s disease and related dementia
- Chronic Kidney Disease
- Cancer (almost all cancers)
- Glaucoma
- Anemia
- Asthma
- Chronic Obstructive Pulmonary Disease
- Diabetes
- Hypertension
- Osteoporosis
- Chronic Pain & Fatigue
- Atrial Fibrillation
- Obesity Stroke
- Cataract
- Arthritis (osteoarthritis and rheumatoid)
- Autism Spectrum Disorders
- Depression
- Heart Failure
- Ischemic Heart Disease
- Migraine/ Chronic Headache
- Fibromyalgia
Which Health Care Professionals Can Provide and Bill Care Management Services
Physicians and the following non-physician practitioners (certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants) may bill the CCM services. Only one qualified health care practitioner may be paid for the Medicare CCM service for a given calendar month. The CCM service may be billed most frequently by primary care physicians, although specialty physicians who meet all of the billing requirements may bill the service. The CCM service is not within the scope of practice of limited license physicians and practitioners such as podiatrists, clinical physiologists, or dentists; therefore, these practitioners cannot furnish or bill for CCM.
However, CMS expects referral or consultation with such physicians and practitioners by the billing practitioner to coordinate and manage care. Medicare CCM services can be done under general supervision, which allows care managers and care coordinators to be located outside of the office.
What does a chronic care manager do?
The chronic care manager is primarily focused on completing comprehensive care plans for patients if the provider does not want to complete the care plan themselves. They can provide care coordination services and recurring ccm services if needed.
What does a care coordinator do?
A chronic care coordinator usually provides ongoing care coordination services once the care plan is done.
What is a PCM Eligible Chronic Condition?
Principal Care Management services can be billed for Medicare beneficiaries with one serious high-risk chronic condition. To qualify for principal care management billing, the condition needs to last at least 3 months, and requires frequent adjustments in the medication regimen and/or the management of the condition due to comorbidities. Additionally, the chronic condition needs to be of sufficient severity to place the patient at risk of hospitalization or have been the cause of a recent hospitalization.
How Much Does Medicare pay for chronic care management?
In order to bill for Medicare’s chronic care management or principal care management service code(s), the development or revision of a chronic condition(s) specific care plan needs to be completed. There are five care planning codes:
HCPCS G0506 ($62.64) is billed when a qualified health care physician or mid-level initiates the care plan in an office visit and completes it after the office visit.
CPT Code 99491 ($86.17) is billed if the qualified health care physician or mid-level completes the comprehensive care plan outside of the office visit if the time taken is between 30 – 59 minutes.
CPT Code 99437 ($61.25) is billed along with CPT Code 99491 if the qualified health care physician or mid-level completes the comprehensive care plan outside of the office visit if the time taken is 60+ minutes.
CPT Code 99487 ($64) is billed for a complex CCM and requires medical decision-making of moderate to high complexity and establishment, implementation, revision, or monitoring of a comprehensive care plan. This CPT Code is billed if a comprehensive care plan is completed by an RN care manager under general supervision if the time it takes is between 60-89 minutes.
CPT Code 99489 ($48) is billed for a complex CCM along with CPT Code 99487 if a comprehensive care plan is completed by an RN care manager under general supervision if the time it takes is 90+ minutes.
Once the comprehensive care plan is completed, in the following month recurring ccm services can continue until a revision of the CCM care plan is needed There are two (2) CCM codes that can be billed for clinical staff time for ongoing ccm services. The CPT Code 99490 is billed once the initial scope of services is met and the time spent is between 20 to 39 minutes. If the time spent is between 40 to 59 minutes, the CPT Code 99439 can be billed to Medicare with the CPT Code 99490. If 60+ minutes are spent the CPT Code 99490 can be billed with 2 units of the CPT Code 99439.
If the provider provides the recurring care management services that meet the scope of service and the time element of 30 to 59 minutes the CPT Code 99491 can be billed. If the scope of service and the time element exceed 60+ minutes the provider can bill CPT Code 99491 and CPT Code 99439 for the service completed.
To find more detailed information for your specific locality to bill for these CPT Codes please click here or go to our ccm page and scroll down to the calculator or go to the Medicare fee schedule. Please note, your payment may be higher due to all your Medicare bonuses from Meaningful Use, MIPS and/ or being part of an APM from an ACO.
How do you implement chronic care management?
Prior to executing a ccm program at a practice, it is important to have a solid implementation plan so patients don’t slip through the gaps while gaining their consent as well as explaining to the patient specifically with the chronic conditions they have how these ccm services will be a benefit to them. The more the patient understands how these services can benefit them the more likely they will participate and continue on to receive these services for years to come.
If the provider or clinical staff has the time to help gain the ccm consents a practice will usually gain the highest number of patients receiving the service since the patients already have a trust built in with their qualified health care professional they see.
Then, the practice needs to stay organized to make sure that all the Medicare patients they have seen within the last year that have multiple chronic conditions discuss the value of the CCM services to gain their consent and on an ongoing process to continue to pull reports to gain additional CCM consents as new patients are added to the practice.
It is important once the CCM consent is gained that soon after a chronic care management plan is put in place. Otherwise, the patient may forget what the CCM service is about and not participate later. Practices still have written consents that are signed in the office but many prefer to do verbal consents instead of written consents since the patients may just sign off on a written consent but not actually read the consent as they are quickly trying to sign all of the CCM documents with other document to be seen for their office visit.
It is always better to have a personal touch and allow staff and/or providers to verbally discuss how the CCM services are applicable to the patient to get the largest buy in and provide continued service for years to come. Also, it it important to point out to the patient that this is a telehealth service that can be done in the comfort of their home and they do not need to come into the office in person to receive this CCM service.
The Challenges of Chronic Care Management
Putting together a chronic care management program can be challenging. There are many items that need to be considered when putting a ccm program together such as:
- The additional time it will take your staff, physician, mid-level and other practice resources to perform the services in compliance,
- Deciding if third party software is needed,
- The time it will take to manage the internal resources as well as auditing the ccm program to make sure it is in compliance every month with not only time but the scope of services being met prior to billing for ccm services.
Additionally, you need to find the right type of services to hire and budget for the cost of hiring, training and paying for the resources. If you decide you would rather give this burden to a chronic care management firm you are able to outsource these services since billing for CCM services can be provided under general supervision.
What place of service is used for chronic care management?
For CCM, the place of service should be the provider’s office or location code 11.
What are the top 3 chronic diseases?
Diabetes, heart disease and cancer are the top 3 chronic diseases in a CCM plan.
Does Medicare Part B cover chronic care management?
Yes, Medicare Part B covers a chronic care management program.
How long does a chronic disease management plan last?
A comprehensive care plan lasts until a revision to the program is needed such as a new chronic condition is added. If a revision has not taken place in the last year usually a qualified care manager will review the care plan on an annual basis to see if further updates need to be done.
To learn more information about the Connected Care campaign, the CMS (Centers for Medicare and Medicaid) Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration please click here.
