Chronic Care Management (CCM) is a program designed to help healthcare providers manage and coordinate care for patients with two or more chronic conditions. Medicare chronic care management aims to enhance patient outcomes through coordinated and comprehensive care, reducing emergency room (ER) visits, hospital admissions and increasing patient satisfaction.
Introducing CCM into your practice may pose challenges but can also benefit both patients and providers. To implement Medicare Chronic Care Management in your practice effectively, here is a step-by-step guide:
- Evaluate your practice’s readiness: The initial step in implementing CCM involves assessing your practice’s readiness, evaluating your patient population’s needs, your staff’s skills and training, and your electronic health record (EHR) system’s capabilities.
- Establish a CCM team: After assessing your practice’s readiness, assemble a team to implement and manage the CCM program. This care team should consist of care managers for care planning and care coordinators responsible for providing ongoing care management services to the patient along with the care managers, as well as any other relevant staff members who will be involved in patient health care.
- Identify eligible patients: The next step is identifying patients who meet the eligibility criteria for CCM services. To qualify for CCM, patients must have two or more conditions that are anticipated to persist for a minimum of 12 months or until the patient’s death.
- Obtain patient consent: Before providing CCM services, it is essential to obtain the patient’s consent, which can be through verbal consent or through a signed agreement. This must be documented thoroughly in the patient’s medical record for proper record-keeping.
- Develop a comprehensive care plan: Once you have identified eligible patients and secured their consent, you must develop a comprehensive care plan for each patient. This care plan should include a detailed list of the patient’s chronic conditions, medications, and any other pertinent health information relevant to their care.
- Provide ongoing care management: The care team (i.e. care manager, care coordinator, and provider) should provide continuous care management services to eligible patients, which include regular check-ins to provide a medication management, and facilitating referrals to other healthcare providers as necessary among other activities to bridge gaps in care and improve health outcomes for the patients.
- Document and bill for CCM services: Lastly, it is important to accurately document all CCM services provided and bill for them appropriately. Medicare provides reimbursement to providers for CCM services at an average rate of $62.69 per patient for 20 to 39 minutes per month (CPT Code 99490) and an additional $47.44 for each additional 20 minute increment with a maximum use of this add-on code (PT Code 99439) to be used up to two times in a calendar month.
Implementing Chronic Care Management into your practice can be a valuable way to enhance patient outcomes and increase revenue. By diligently following these steps, you can establish a successful chronic care management program that benefits your patients and your practice.
How Specialists Can Incorporate Chronic Care Management (CCM) into their Service Offerings
Specialists can incorporate Chronic Care Management (CCM) into their service offerings to facilitate more coordinated and comprehensive care for patients with chronic conditions. Although primary care physicians are typically the main providers of CCM services, specialists who treat patients with chronic conditions can also offer these services to improve patient health care. A specialist can decide if they want to provide CCM services for all their chronic conditions if they have not received this service elsewhere or if they would like to focus on a single complex chronic condition for the patient they treat to provide extra support in between office visits and bill for Principal Care Management (PCM) services instead of Chronic Care Management services. Most specialists bill for Principal Care Management services instead of Chronic Care Management services.
In order to be eligible for PCM services, specialists must be enrolled in Medicare and meet the following requirements:
- The specialist must have an in-person or telemedicine evaluation with the patient and establish or reestablish a care plan that includes the management of at least one chronic disease within the last year.
- The specialist needs to utilize a certified electronic health record (EHR) system that can generate an individualized care plan or work with a Principal Care Management software (ie CareVitality) to document the care plan for the single high risk chronic condition.
- The specialist should ensure 24/7 access to care management services and possess the capability to communicate electronically with patients.
- The specialist or care team member (usually nurses) must deliver a minimum of 30 minutes of non-face-to-face care management services per month to the patient.
Once a specialist fulfills these prerequisites, they can begin providing PCM services to eligible patients. To do so, they must follow these steps:
- Identify eligible patients: Specialists should identify patients who have been diagnosed with a single high risk chronic condition that requires continuous management.
- Obtain patient consent: The specialist is required to obtain written consent from the patient before receiving PCM services.
- Develop a comprehensive care plan: The specialist should create a care plan for the patient’s high risk chronic condition.
- Provide ongoing care management and care coordination: The specialist and/ or their care team should offer continuous care management services to the patient, such as regular check-ins, medication management, allergy updates, transitional care management services if needed, preventative care management, care coordination and facilitation of referrals to other healthcare providers as necessary, medication refills, etc…
- Document and bill for PCM services: It is crucial to accurately document all PCM services provided to fulfill the scope of services requirements and bill for them appropriately. Medicare provides reimbursement to providers for PCM services differently if an eligible physician or qualified health care professional is giving the service or their care team member which can be provided under general supervision.
If an eligible physician or qualified health care professional provides the service the initial 30 minutes of time spent is billed as CPT Code 99424 for an average national payment amount of $83.40 per patient per month and if an additional 30 minutes is spent in the calendar month then another add on code CPT Code 99424 can be billed which the average national payment amount is $60.22.If an eligible physician or qualified health care professional’s clinical staff member provides the service the initial 30 minutes of time spent is billed as CPT Code 99426 for an average national payment amount of $63.33 per patient per month and if an additional 30 minutes is spent in the calendar month then another add on code CPT Code 99427 can be billed which the average national payment amount is $48.45.
In summary, specialists who offer care for patients with chronic conditions can incorporate CCM into their service offerings or if focusing on a single high risk condition they are treating and incorporate PCM services instead by fulfilling Medicare’s requirements, identifying eligible patients, obtaining patient consent, creating a comprehensive care plan for CCM or singe high risk condition for PCM services, deliver ongoing care management and care coordination to fulfill the required scope of services, provide detailed document of the services, document the time the services were provided, and bill appropriately for CCM or PCM services provided.
Eligibility Requirements for Chronic Care Management (CCM) Services for Patients
In order to qualify for Chronic Care Management (CCM) services, patients must meet the following requirements:
- Have two or more chronic conditions: Patients must have at least two chronic conditions that are anticipated to last at least 12 months or until the patient’s death or the condition places the patient at significant risk of death, acute exacerbation or decompensation or physical decline.
- Have a Medicare Part B fee-for-service plan: To be eligible for CCM services, patients must have a Medicare Part B fee-for-service plan. Patients with Medicare Advantage plans are qualified for CCM services, too.
- Provide consent for CCM services: Patients need to provide written or verbal consent to receive CCM services. This consent can be obtained during an in-person visit with their healthcare provider, through a secure electronic platform or verbally through telephonic means.
- Have a comprehensive care plan: Patients must possess a comprehensive care plan that outlines their chronic conditions along with their goals and interventions, medications, allergies and other pertinent health information. The eligible physician or qualified healthcare professional should develop a care plan that undergoes regular reviews and updates. A comprehensive care plan can be initially created by their RN Care Manager and later can be reviewed by the healthcare provider for any additional revisions if needed and signed off by the healthcare provider to be sent to the patient.
- Have access to a care manager and/or care coordinator: Patients must have access to a care manager and/ or care coordinator who can offer continuous care management services, including regular check-ins, medication management, and care coordination services such as facilitation of referrals to other healthcare providers, refill requests and preventative care reminders.
It is important to note that patients do not need to have a primary care provider to qualify for CCM services. They can receive these services from any qualified healthcare professional who is enrolled in Medicare and provides CCM services. However, usually these services are given by a primary care provider.
Basic Requirements for the Initial Visit for Chronic Care Management for Medicare
The initial visit for Chronic Care Management (CCM) is an essential component of the program, as it establishes the patient’s eligibility and can be used to develop a comprehensive care plan. However, if the initial visit has been done in a prior year and this patient qualifies for the CCM services then a verbal or written consent needs to be gained as long as the patient has had an office or telemedicine visit within the last year to initiate the CCM services. Below are the basic requirements for the initial visit:
- Face-to-face visit: To establish eligibility for CCM services, the patient must visit their healthcare provider in person or via telemedicine within the last year. During this visit, the provider has the opportunity to explain the CCM program and the benefits to the patient to obtain their written or verbal consent to participate. It is not required to gain the consent within this visit and can be done at a different time but if the consent is gained in this visit the provider can initiate the comprehensive care plan billed at this time and complete it att this time or a later time and bill CPT Code G0506 for their work.
- Comprehensive assessment: The provider must assess the patient’s health status comprehensively, such as reviewing their medical history, medications, and any of their chronic conditions. The provider should identify any care gaps and assess any potential risks to the patient’s health if the care plan is being completed due to initiating it during this initial visit.
- Development of a care plan: The provider is responsible for developing a comprehensive care plan in the initiating visit that outlines the patient’s chronic conditions, medications, and other relevant health information. The care plan should be individualized and based on the unique needs and goals of the patients. Once the comprehensive care plan is completed the patient needs to receive a copy of this care plan either electronically or a printed copy of the comprehensive care plan.
- Patient education: Patients must learn about their chronic conditions, self-management strategies, and medications. The patient should also receive tools and resources, such as educational materials and referrals to community resources, to help them manage their health care effectively.
- Care coordination: The provider must effectively coordinate care with other healthcare professionals involved in the patient’s care, including specialists.
If a provider initiates the comprehensive care plan within the initial visit they can complete this care plan after the visit and bill for the CPT code G0506 which would pay the provider $62 for providing this service. If the provider wishes to have his RN care manager to create the comprehensive care plan for the provider to review revise if needed and sign off on ot then the provider can bill CPT 99487 for the first 60 to 89 minutes of comprehensive care planning (National Payment Amount – $133) and CPT Code 99489 (National Payment Amount – $70) as an add on code if the service goes 90 minutes or beyond.
Obtaining Patient Consent for Qualified Health Services for Medicare Chronic Care Management Services
Acquiring patient consent is an important step in delivering Medicare Chronic Care Management (CCM) services. It is imperative to obtain patient consent before providing any CCM services, and it must be properly documented in the patient’s medical record. The following are the key elements of obtaining patient consent for CCM services:
- Explanation of services: The healthcare provider or their staff must clearly explain the details of the CCM program and the services that will be provided to the patient. This includes explaining the potential benefits of the program, the non-face-to-face care management services, the patient’s financial responsibilities under the program, the fact that Medicare will only pay for this service from a single provider which is important to make sure the patient has not signed up with another healthcare provider and is receiving this service already. Otherwise, the provider who is the first to send in the claim for the service for a given calendar month would be the one who is paid for this service.
- Consent: The healthcare provider or their staff must provide the patient with a comprehensive description of the CCM program and the services provided along with the patient’s rights and responsibilities within the program, associated cost of the services, and the patient’s right to revoke their consent at any time.
- Consent agreement: The patient must give a verbal consent or sign the consent form indicating their agreement to participate in the CCM program.
- Copy of consent form: The healthcare professional is responsible for saving documentation of the consent in the patient’s medical record.
How to receive Medicare Chronic Care Management Reimbursement
Valuable tips to ensure that your practice receives the appropriate reimbursement Medicare Chronic Care Management services reimbursement are as follows:
- Understand the requirements: Ensure that you understand the requirements for delivering CCM services and billing for them. These requirements include obtaining patient consent, creating a comprehensive care plan, and offering a minimum of 20 minutes of non-face-to-face care management and care coordination that fulfill the CCM scope of services per month.
- Use a qualified healthcare professional: Qualified healthcare professionals, including physicians (MDs, DOs), physician assistants, nurse practitioners, or clinical nurse specialists, are the only ones eligible to provide CCM services.
- Accurately document services: Ensure that all CCM services, including the time spent on non-face-to-face care management and care coordination services, are accurately documented in the patient’s medical record to fulfill the required scope of services.
- Use the correct billing codes: When submitting claims for CCM services, it is important to use the accurate billing codes. The CPT codes for CCM services are 99490, 99439, 99491, 99437, 99487, and 99489.
- Use a certified EHR: Use a certified Electronic Health Record (EHR) system to document CCM services, which involves the ability to track the time spent on these non-face-to-face care services.
- Train staff: Ensure that all staff involved in delivering and billing CCM services are well-trained on the requirements and for providing and billing these services.
- Monitor compliance: Consistently monitoring staff compliance with CCM scope of service and billing requirements to ensure that all services are being provided, documented, and billed accurately.
- Consider outsourcing: Consider outsourcing CCM services to a third-party provider specialized in delivering and billing these services, ensuring that all requirements are fully-met and potentially increasing reimbursement rates.
Implementing these tips and tricks can increase the likelihood of receiving accurate reimbursement for Medicare Chronic Care Management (CCM) services in your practice.
Concurrent Billing Requirements for Other Care Management Programs
Apart from Medicare Chronic Care Management (CCM) services, other care management programs present billing opportunities, including:
- Behavioral Health Integration (BHI): Healthcare providers provide BHI services to patients diagnosed with behavioral health conditions, including anxiety or depression. BHI services include an initial assessment, treatment plan development, and continuous care management and care coordination services. The billing codes used for BHI services are 99492 (for initial psychiatric collaborative care management) and 99493 (for each additional month of psychiatric collaborative care management) and CPT Code 99484 (behavioral health integration) for non-face-to-face services for therapy management and coordination in between office visits or telemedicine visits.
- Principal Care Management (PCM): Patients diagnosed with a single complex chronic condition, such as Parkinson’s disease or Multiple Sclerosis, can receive PCM services, which include at least 30 minutes of care management and care coordination services per month and can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist or a provider’s care team under general supervision. The billing codes for PCM are 99424, 99425, 99426, and 99427.
- Transitional Care Management (TCM): Healthcare providers offer TCM services to patients who are discharged from one of the following settings to their home, domiciliary, rest home or assisted living facility: Inpatient Acute Care Hospital, Inpatient Psychiatric Hospital, Long Term Care Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility, Hospital outpatient observation or partial hospitalization; Partial hospitalization at a Community Mental Health Center. TCM services can be billed for up to 30 days after discharge and include an initial visit within 7 to 14 days of discharge, non-face-to-face communication, and provided telehealth services within the 30 days of discharge. The billing code used for TCM services is 99495 (for moderate complexity) or 99496 (for high complexity).
- General Care Management (GCM): Patients diagnosed with complex chronic conditions, such can receive GCM services if they are part of a FQHC or rural health clinic, which include at least 20 minutes of care management and care coordination services per month once a comprehensive care plan is established after a patient gives consent for these services and can be provided by a physician, physician assistant, nurse practitioner, clinical nurse specialist or a provider’s care team under general supervision. The single billing code for GCM services is CPT Code G0511 and pays $70.26 according to the CMS Fee Schedule for 2023 . GCM services are comprehensive and include services for chronic care management, principal care management, behavioral health integration, transitional care management and remote physiologic monitoring.
- Remote Physiologic Monitoring: Patients who are diagnosed with a chronic condition that can benefit from a remote physiologic device, such as Diabetes, Congestive Heart Failure (CHF), Hypertension, Obesity, and COPD, can receive RPM services along with a remote physiologic monitor, which include at least 20 minutes of remote physiologic monitoring services and care coordination services per month and can be provided by a physician, physician assistant, nurse practitioner, or clinical nurse specialist or a provider’s care team under general supervision. The billing codes for RPM are CPT Code 99091, 99453, 99454, 99457 and 99458. CPT Code 99091 is for collecting and analyzing physiologic data by a provider. CPT code 99453 is for providing set-up and training of the device for the patient. CPT Code 99454 is for 16 days of patient Monitoring. CPT Code 99457 is for remote physiologic monitoring (RPM) services for the initial 20 to 39 minutes. CPT Code 99458 is for each additional 20 to 39 minute interval of remote physiologic monitoring services to be billed along with CPT 99457. CPT Code 99458 can be billed up to 2x per calendar month.
It is important to note that healthcare providers can concurrently bill for CCM services and other care management programs, as long as the services offered are distinct and separately identifiable. For example, they can bill for both CCM, TCM, and/ or RPM services for the same patient during the same month, as long as the services provided are not duplicative and the time threshold is met separately for each service code as long as their respective scope of service is met. Usually a provider would pick if they are providing CCM or PCM services and do not bill both in a given calendar month.
General care management services are for services in FQHCs (Federally Qualified Health Centers) or rural health clinics and are only able to bill G0511 since they receive a flat rate to include CCM, BHI and and RPM services for a patient). Therefore, FQHCs or rural health clinics are unable to bill for CCM, BHI or RPM service codes since those services are included in GCM.
In conclusion, understanding the opportunities and requirements for concurrent billing of different care management programs can help providers maximize their reimbursement and deliver comprehensive patient care.
People Also Ask Questions
Does Medicare Advantage cover CCM?
Medicare Advantage plans are reimbursing for CPT 99490. A small minority of Medicare Advantage reimbursement of 99490, have a coinsurance which may be a barrier to enrolling patients. It is always helpful to double check with the Medicare Advantage plans to see which ones leave the patient with a coinsurance to be able to discuss this with your patients upon gaining their consent.
Can CCM and home health be billed together?
No CCM and home health cannot be billed together.
How long does a chronic disease management plan last?
A chronic disease management plan is usually reviewed at least once a year but can be reviewed earlier if there has been a change in a provider’s treatment plans and/ or a new diagnosis has been added.
How often can you bill chronic care management?
Chronic care management can be billed once per calendar month.
Can you bill for TCM and CCM?
Yes, TCM and CCM can be billed in the same month.
Does Medicare Part A cover CCM?
No, Medicare Part A does not cover CCM.
What diagnosis codes qualify for chronic care management?
Diagnoses that are considered chronic qualify for chronic care management. A list of the majority of chronic conditions can be found in the CMS Chronic Condition Data Warehouse.
