CMS Chronic Care Management (CCM) Services are services provided to patients with multiple chronic conditions. These services are used to improve the quality and coordination of care for patients with complex medical needs. As a healthcare provider, offering CCM services can help you improve patient outcomes, help you provide better care to your patients and increase your practice’s revenue.
To offer CCM services, your practice must meet certain requirements, including:
- Have a qualified healthcare professional (QHP) designated to provide and/or oversee the CCM services.
- Utilize a certified electronic health record (EHR) system to document and manage the CCM services.
- Obtain a patient’s consent to receive CCM services and bill for them.
- Offer patients 24/7 access to care and a comprehensive care plan for their chronic conditions and urgent care needs.
- Provide patients with a copy of their comprehensive care plan.
Once a comprehensive care plan is completed and signed off by a provider a patient can receive ongoing services each month as long as the minimum time threshold of at least 20 minutes or more of services is done and complete the scope of service for all the chronic conditions is met for providing CCM services, then, you can bill for CCM services provided to Medicare patients. CCM services are reimbursed on a monthly basis and can provide an additional revenue stream for your practice.
To ensure the success of your CCM program, it is important to communicate effectively with your patients the benefits of CCM services specifically to their specific chronic conditions and the importance in their participating in the service to help in managing their chronic conditions.
In summary, CCM services can be valuable for your practice to offer, improve patient care and allow you to generate additional revenue by helping patients be healthier in their homes helping them avoid unneeded ER visits, compilations, and potential hospitalizations.
How Have Chronic Care Management Practices Changed?
Chronic care management practices have changed in recent years to be applicable for more providers. As reported in the American news the government has shifted towards value-based care, improved interoperability standards towards connected care among Healthcare Information Technology systems, advances in technology, and changes in healthcare payments and policies have all been a part of these changes. Here are some of the ways that chronic care management practices have changed:
- Strong focus on collaborative patient-centered care: There is now a greater emphasis on providing a more collaborative approach to patient-centered care by involving the patient and their caregivers in their care, which takes into account the patient’s particular preferences and needs.
- Improved Interoperability Standards: In the beginning of the pandemic, March 2020, national standards were announced to help improve the interoperability among health care information technology systems to help them communicate more effectively among one another and transfer patient related information in a secure manner and efficient manner to help improve care and save lives of patients across different settings of care which has greatly improved rural health care.
- Improved Technology: Health care information technology has played a significant impact in the transformation of chronic care management practices. Electronic health records (EHRs), patient portals, telemedicine, and remote patient monitoring tools have all made it easier to coordinate care and manage chronic conditions.
- Prevention Focus: There has been a strong focus on preventing chronic conditions through early detection, management and monitoring such as conducting regular screenings, lifestyle changes, and early intervention to prevent the progression or development of chronic conditions.
- Integration of behavioral health: The integration of behavioral health into management chronic care practices has become more prevalent since the pandemic and the introduction of these new behavioral health integration (BHI) codes. This involves identifying and addressing behavioral health issues that may be contributing to chronic conditions and lead to increased stress which can effect their chronic condition, such as depression, anxiety, and bipolar disorder.
- Increased reimbursement: With the introduction of new reimbursement models, increased payment models, such as the Medicare Chronic Care Management program and additional care management chronic care programs, healthcare providers are now being reimbursed at higher rates for providing chronic care management services. This has incentivized healthcare providers to focus more on chronic care management and to develop new models of care in their organization to better manage chronic conditions more effectively.
Overall, chronic care management practices have become more patient-centered, more collaborative, interoperability focused, technology-driven, and focus on prevention and early intervention. These changes have helped to increase access to care, improve patient outcomes and reduce costs.
What Patients are Eligible for Care Management Services?
Patients who are eligible for care management services need to have chronic condition(s) expected to last at least 12 months or until the patient’s death and or place them at significant risk of death, acute exacerbation and or decompensation, or functional decline
The Centers for Medicare & Medicaid Services (CMS) defines chronic conditions as conditions that:
- Have a qualified healthcare professional (QHP) designated to provide and/or oversee the CCM services.
- Utilize a certified electronic health record (EHR) system to document and manage the CCM services.
- Obtain a patient’s consent to receive CCM services and bill for them.
- Offer patients 24/7 access to care and a comprehensive care plan for their chronic conditions and urgent care needs.
- Provide patients with a copy of their comprehensive care plan.
Chronic Care Management services can also help health equity.
Examples of chronic conditions that may qualify a patient for care management services include the following:
- Arthritis (osteoarthritis and rheumatoid)
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer
- Cardiovascular disease
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic Kidney Disease
- Depression
- Diabetes
- Hypertension
- Infectious diseases like HIV and AIDS
In addition to having two or more chronic conditions for a provider to bill for chronic care management services, patients must provide written or verbal consent to receive care management services, have a comprehensive care plan in place, and have access to a care manager and care coordinator who can coordinate their care and provide the full scope of services and minimum time requirement if billing for specific chronic care management code(s).
If the patient has a minimum of one complex chronic condition a specialist can bill for care management services called principal care management services. Some organizations may offer care management services who are at high risk for developing chronic conditions. Healthcare providers should review the specific program(s) or to determine eligibility criteria.
Best Practices for Care Management Reimbursement
Some best practices for care management reimbursement are as follows:
- Understand the billing codes: It is important to learn the various billing codes for care management services, including the time and scope of service required to provide each service, and the reimbursement rate.
- Educate patients on the benefits of care management services: Educate patients on how care management services can improve their health outcomes. Encourage patients to enroll in receiving care management programs and explain the billing process to them in case they have not reached their deductible or do not have a secondary insurance to cover their coinsurance.
- Train clinical staff on care management services: Ensure the clinical staff members chosen to provide these care management services have the necessary skills to deliver high-quality care. Then, train the chosen clinical staff on the scope of services required to be completed and documented before billing for care management services.
- Streamline care management services by using appropriate technology: Use technology such as electronic health records (EHRs) and care management software to streamline care management services. Using specific are management technology can help optimize workflow, create time efficiencies, improve documentation, decrease administrative burdens, and enhance communication with patients.
- Develop efficient care management service workflows: Develop processes and workflows for care management services, including patient identification, enrollment, and ongoing management of patients. This can help assire that care management services are delivered consistently, effectively, and efficiently.
- Track and monitor care management services: Tracking and monitoring care management services help ensure that they are being delivered in a timely manner as intended for patients to receive high-quality care. Data analytics and performance metrics can be used to identify areas for improvement for clinical staff and refine care management workflows and processes.
Implementing these care management best practices allows healthcare providers to effectively and efficiently manage patients with chronic conditions, improve patient outcomes, and maximize reimbursement for care management services.
What Services Need to Be Provided by a Health Care Professional?
Care management services provided by health care professionals must perform a range of tasks to ensure that patients receive high-quality care. Examples of the services to be provided by a healthcare professional include:
- Comprehensive assessments: A healthcare professional should perform comprehensive assessments of a patient’s health, including physical, mental, and social needs. This involves gathering information about a patient’s medical history, any social or environmental factors, and current health status which may affect their health.
- Comprehensive care plan development: A healthcare professional should develop a comprehensive care plan based on the assessment that outlines the patient’s treatment goals, interventions/ instructions, and anticipated outcomes. This care plan should include information about the patient’s needs, preferences, values, and goals.
- Care Coordination: A healthcare professional should coordinate care with other members of the patient’s care team, including primary care providers, specialists, social services, caregivers and community resources. This involves ensuring that all providers have access to the patient’s care plan and that care is delivered in a patient-centered, coordinated, and integrated manner.
- Regular patient monitoring and follow-up: A healthcare professional should monitor a patient’s progress regularly, adjust their care plan when needed and provide ongoing support and education to help manage the patient’s condition and achieve their treatment goals.
- Medication management: A healthcare professional should help manage a patient’s medications, reconcile whether they are taking their medications as prescribed, monitoring drug interactions and side effects, and modify their medication regimens as needed.
- Patient and family education: A healthcare professional should provide education to patients, caregivers, and their families about their condition, treatment options, and effective self-management strategies such as lifestyle modifications (i.e. diet and exercise) to help improve the patient’s health outcomes.
By providing these care management services, healthcare professionals can help patients effectively manage their chronic conditions, improve their health outcomes, improve their quality of life, and decrease the risk of hospitalizations and complications.
Initial Visit for CMS
Before CCM services can be offered, there must be an initiating face-to-face visit with a Medicare qualified health care provider (QHP) for patients who have not been seen within one year prior to the commencement of CCM services or for new patients. The initiating visit can be an initial preventive physical exam, a medicare annual wellness visit, transitional care management visit, or other qualifying evaluation and management visit. This visit is billed separately and is not part of CCM services.
During the initial visit, the healthcare professional should perform a comprehensive assessment of the patient’s health, including their medical history, existing chronic conditions, current medications, allergies, social determinants of health and review the patient’s health status.
After the assessment, the healthcare professional should develop a comprehensive care plan that outlines the patient’s treatment goals, interventions, and anticipated outcomes and include information about the patient’s preferences, values, and goals.
During the initial visit, the healthcare professional should also explain the CMS CCM services to the patient and obtain their verbal or written consent to participate in receiving these services. As part of gaining the consent the healthcare professional should also explain the billing process, any potential out-of-pocket costs to the patient, and that only one provider can bill for these services in any given month to make sure they have not enrolled for these services with another provider already.
The initial visit allows the healthcare professional to build a relationship with the patient and establish trust. The provider can take the time to understand the patient’s needs and preferences to help develop a comprehensive care plan to help the patient manage their chronic conditions more effectively, improve their quality of life, reduce the overall cost of care, and decrease the risk of complications, ER visits and hospitalizations.
Once the initiating visit has been provided (for new patients or those not seen within a year of the commencement of CCM services) and CCM consent is gained, a comprehensive care plan for CCM is developed.
An add-on face-to-face visit, HCPCS Code G0506, may be billed to complete the person-centered plan if it is initiated in a face-to-face visit and complete in this visit or after.
In this face-to-face visit, a provider will identify the patient’s chronic conditions and develop a comprehensive care plan that can be completed after the face-to-face visit. Otherwise, a care plan can be completed via non-face-to face-services and billed CPT Code 99487 and/ or CPT Code 99489.
How Principal Care Management and Chronic Care Management Services Connect Patients
Principal Care Management (PCM) and Chronic Care Management (CCM) services are ways to perform care management and aim to connect patients with the resources and support they need to manage their chronic condition(s) effectively.
PCM services provide comprehensive care management for patients with complex medical needs for a single complex chronic condition usually overseen by a specialty provider. PCM services include coordinating care with multiple health care providers, ensuring that the patient receives appropriate interventions and treatments, and providing ongoing support and education to help the patient manage their condition.
CCM services provide comprehensive care management to patients with multiple chronic conditions. CCM services involve regular check-ins with a qualified healthcare professional (QHP) and/or clinical staff, medication management, preventative care reminders, assistance with any transitions of care, transportation assistance, and care coordination with other providers.
Both PCM and CCM services aim to connect patients with the resources they need to manage their conditions effectively. This includes coordinating care with other providers, providing education and support to help the patient manage their chronic condition, and helping the patient receive appropriate treatments and interventions to best manage their chronic condition.
By connecting patients with the appropriate clinical resources, CCM and PCM services can help improve patient outcomes, potentially reverse chronic conditions, reduce the risk of hospitalizations and complications, and enhance the overall quality of care.
Chronic Care Management & Principal Care Management Codes for 2023
The Centers for Medicare and Medicaid Services (CMS) have the following Chronic Care Management (CCM) and Principal Care Management (PCM) codes for 2023:
CCM codes
Chronic care management services can be billed for at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month once the following elements are met and the full scope of services are completed:
- The patient has multiple chronic conditions expected to last at least 12 months, or until the death of the patient.
- The chronic conditions place the patient at significant risk of death, decompensation or acute exacerbation, or functional decline.
- Comprehensive care plan established, implemented, revised or monitored
Add on code to be billed with CPT code 99490 for each additional 20 minute interval of service beyond the initial 20 to 39 minutes of service billed with CPT code 99490. CPT code 99439 can be billed up to twice in a calendar month along with CPT 99490.
Chronic care management services, provided by a physician or other qualified healthcare professional (QHP) for at least 30 minutes or more of physician or other qualified healthcare professional (QHP) time, per calendar month, with the following elements:
- Patient has two or more chronic conditions expected to last at least 12 months, or until the death of the patient.
- The patient’s chronic conditions place the patient at significant risk of death, functional decline, acute exacerbation, or decompensation
- Comprehensive care plan is established, implemented, revised or monitored.
Add on code to be billed with CPT code 99491 for an additional 30 minutes or more of CCM services time spent and the required scope of service is given by a physician or other qualified health care professional (QHP), per calendar month.
Complex CCM code that requires medical decision making of moderate to high complexity and establishment, implementation, revision or monitoring of a comprehensive care plan and 60 minutes of service is completed to bill for this service.
Once the time element for CPT Code 99487 is met and at least 90 minutes or more of CCM services is completed then CPT Code 99489 can be billed for the additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional (QHP), per calendar month.
It is important to note that these codes are subject to specific billing and documentation requirements to make sure the full scope of services is met. Healthcare providers should review the guidelines for gaining consent and the scope of service requirements to ensure compliance with CMS regulations are met before billing for these CPT codes.
PCM codes
PCM services for a single high-risk chronic condition – first 30 minutes provided personally by a physician or other qualified health care professional (QHP), per calendar month (approx. $81.33 as per CMS Fee Schedule).
PCM services for a single high-risk chronic condition – each additional 30 minutes provided personally by a physician or other qualified health care professional (QHP), per calendar month (approx. $58.29).
PCM services for a single high-risk chronic condition – first 30 minutes of clinical staff time directed by physician or other qualified health care professional (QHP), per calendar month (approx $61.34).
PCM services for a single high-risk chronic condition – each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional (QHP), per calendar month (approx. $47.44).
