What is CMS chronic care management?
CMS Chronic Care Management (CCM) is a program started by the Centers for Medicare & Medicaid Services (CMS) in the United States to improve care for patients with two or more chronic conditions. Chronic care management resources are reimbursable to qualified health providers (QHPs) by CMS for service provided to patients that meet the required scope of service as well as the time threshold to bill for chronic care management services.
Chronic care management services reimburses providers through Medicare to have additional clinical staff to provide non-face-to-face chronic care management, monitoring and care coordination services in between office visits to help improve and/ or maintain a patients’ chronic conditions which will help avoid unnecessary ER visits, preventable hospitalizations, and hospital readmissions. Care coordination with other providers, medication management, and regular check-ins are some of the services included. The program demands a development of a comprehensive care plan defining a patient’s treatment objectives, interventions and anticipated outcomes.
A chronic condition defined by CMS is expected to last at least 12 months or until death of the patient, and places the patient at risk of functional decline, decompensation/ acute exacerbation, or significant risk of death. Additionally, prior to providing ccm services a comprehensive care plan should be established, implemented, revised when needed and or monitored.
The goal of the CCM program is to reimburse healthcare professionals to deliver an extensive and coordinated plan of care to patients with chronic conditions. The CCM program is designed to reduce healthcare costs, enhance patient outcomes, and improve quality of care for patients.
What conditions qualify for chronic care management?
To qualify for Chronic Care Management (CCM) services, a patient must have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient. An example of qualified Medicare chronic conditions are as follows:
- Arthritis (osteoarthritis and rheumatoid arthritis)
- Asthma
- Atrial fibrillation
- Bipolar disorder
- Chronic Obstructive Pulmonary Disease (COPD)
- Depression
- Diabetes
- Heart failure
- Hypertension
- Hyperlipidemia
- Ischemic heart disease
- Obesity
- Osteoporosis
- Parkinson’s disease
- Schizophrenia
- Tobacco use
A more detailed list of chronic conditions is available on the CMS Chronic Condition Data Warehouse. Not every chronic condition is listed on this Data Warehouse but if it meets the definition of a chronic condition it will qualify.
What does CMS consider a chronic qualified health condition?
According to CMS, a chronic condition is expected to last at least 12 months or until the patient’s death and would place the patient at significant risk of death, acute exacerbation and or decompensation, or functional decline.
How many minutes are required for Medicare chronic care management?
A minimum of 20 minutes are required along with meeting the full scope of CCM services in order to bill for medicare chronic care management services.
Can an LPN do chronic care management?
Yes, under the general supervision of a physician or other qualifying healthcare professional (QHP) a licensed practical nurse (LPN) can engage in providing Chronic Care Management (CCM) services. According to Centers for Medicare & Medicaid Services (CMS) guidelines, clinical staff, including LPNs, can provide the 20 minutes or more of non-face-to-face care coordination services required for CCM billing. However, a LPN is not allowed to create or revise a comprehensive care plan which needs to be done by a licensed RN or a higher credentialed health care professional who is able to complete this within their licensure.
How often can chronic care management be billed to Medicare?
Chronic Care Management (CCM) services can be billed once per patient per calendar month.
Can CCM and RPM be billed together?
According to the Centers for Medicare and Medicaid Services (CMS), CCM and RPM can be billed together when the services are distinct and separate from each other, and when the time spent on each service is clearly documented, the scope of services is met to fulfill billing each code separately and meets the time requirements are met for for billing each code.
Can you bill PCM and CCM in the same month?
Yes, Principal Care Management (PCM) and Chronic Care Management (CCM) services can be billed to Medicare in the same month, as long as the services provided are distinct and separate from each other, the scope of service is met for each separate service and the time spent on each service is clearly documented and meets the requirements for billing.
PCM services are provided to patients with a single high risk chronic condition who require moderate to high levels of medical decision-making and coordination of care. CCM services are designed to help patients with multiple chronic conditions manage their health and wellness outside of the healthcare provider’s office.
CCM services are designed to help patients with multiple chronic conditions manage their health and wellness outside of the healthcare provider’s office.
Who can make chronic care management calls?
Chronic care management (CCM) calls can be made by healthcare professionals, including physicians, physician assistants, nurse practitioners, clinical nurse specialists, who are authorized to bill Medicare for CCM services along with their clinical staff. These healthcare professionals should have the proper training and expertise to manage and monitor the patient’s chronic conditions and be able coordinate their care.
It is important that healthcare professionals who make CCM calls are knowledgeable about the patient’s medical history and have access to up-to-date information about the patient’s health status, such as medication, allergies, preventative items needed, recent lab results, or other relevant information. This information helps the clinical team provide high-quality care that is based on the patient’s needs and preferences.
During chronic care management calls, healthcare professionals work with patients to develop and/ or utilize care plans, provide education and support to patients and their caregivers, and monitor and adjust treatment plans as needed. Patient’s progress and any change in their health status, as well as the time spent on the stated activities should be well documented in their medical record for the ccm calls.
What are three of the four items of the disease management plan?
Listed below are the items of a disease management plan:
- Assessment and Diagnosis: Identifying the patient’s condition, assessing the disease severity, and determining the appropriate treatment.
- Treatment Plan: This involves creating a plan for managing the patient’s condition, which may include lifestyle changes, medication and other interventions. The treatment plan should be personalized according to the patient’s needs and goals, regularly monitored and revised as needed.
- Monitoring and Follow-up: To ensure that a patient’s condition is being managed effectively, regular monitoring of their conditions and adjusting of treatment plan as needed should be done on a regular basis. This includes Medicare patients who may need to undergo regular testing, check-ins with their healthcare provider and other forms of monitoring.
- Patient Education and Support: Focuses on providing patients with the information, resources, and support they need to manage their condition effectively. This may include education about the condition and how it affects the body, support for lifestyle modifications, and access to support groups and community resources. This will help Medicare patients be more equipped to manage their condition and improve their overall health outcomes.
What are examples of Medicare chronic care conditions?
Below are some examples of chronic conditions:
- Diabetes
- Arthritis
- Hypertension (aka High blood pressure)
- Heart disease (i.e. heart failure, coronary artery disease and arrhythmias)
- Chronic obstructive pulmonary disease (COPD) (i.e. emphysema and chronic bronchitis)
- Mental health conditions (i.e. anxiety, depression, anxiety, bipolar disorder, schizophrenia)
- Asthma
How do I set up chronic care management?
If you are a healthcare provider or a healthcare organization who are interested in setting up a Chronic Care Management (CCM) program, here are some steps that you can follow:
- Identify eligible patients: Assess your patient population to identify those who are eligible for CCM services based on Centers for Medicare & Medicaid Services (CMS) guidelines.
- Develop a care team: Put together a care team that includes a physician or other qualified healthcare provider to manage the program and clinical staff, such as registered nurses or licensed practical nurses, to provide CCM services.
- Establish workflows: Develop workflows on how the CCM services will be provided, which includes identifying Medicare patients who qualify, conducting patient assessments, creating care plans, and providing ongoing monitoring and follow-up.
- Implement technology solutions: Consider using technology to help with CCM services, such as chronic care management technologies.
- Train staff: Provide training to clinical staff about the CCM service requirements, chronic care management software and Medicare workflows.
- Monitor and evaluate the program: Consistently monitor, audit and evaluate the effectiveness of the CCM program, including patient outcomes, time efficiencies, staff satisfaction, and financial performance.
Through these steps, healthcare providers can set up a comprehensive CCM program that helps manage the care of eligible Medicare patients with chronic conditions. It is essential to follow CMS guidelines to ensure proper Medicare billing and reimbursement for CCM services.
What is considered CCM?
CCM Chronic Care Management refers to a healthcare service focused on improving the overall health of patients with chronic conditions. CCM is a collaborative approach to healthcare that involves care teams, including physicians (M.D. or D.O.), physician assistants, nurse practitioners, and other healthcare professionals. The goal of CCM is to provide patients with the support and resources they need to manage their chronic conditions effectively.
CMS defines CCM as a service that provides the following components:
- A comprehensive care plan based on a patient-centered assessment of the patient’s needs, preferences and goals.
- Care coordination among the patient’s healthcare providers
- Patient regular follow up including monitoring of symptoms, medication management, care coordination, preventative screening and immunization reminders
- Transitional care management
- 24/7 access to healthcare professionals supporting urgent needs
In various settings, CCM can be provided by healthcare professionals. These settings include hospitals, primary care clinics, and home health agencies. Services are made available to patients with two or more chronic conditions and are reimbursed by insurance, Medicaid and Medicare.
What can a LPN do that a RN can not?
The scope of practice for Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) varies depending on state laws and regulations. In general, LPNs and RNs have different levels of training, education and responsibilities, which can affect their scope of practice. Listed are examples of tasks that LPNs can do that RNs cannot:
It is important to note, RNs and LPNs work together as part of a health care team to provide efficient, high-quality care to patients. The scope of practice for RNs and LPNs is identified by state laws and regulations, and the policies and procedures of the healthcare organization.
Is Chronic Care Management profitable?
Chronic Care Management (CCM) can provide an additional revenue stream for the management of patients with chronic conditions as long as providing these services are done effectively for the patients to understand the value and stay on the program long term, and the CCM services are implemented to the documentation and time requirements by CMS for a healthcare organization in case faced with an audit they do not get in trouble for fraud and loose money. Therefore, if a practice does not have the staff in place to manage and monitor the care team providing the services it is better to outsource it to a chronic care management firm that can focus on it. Since if a practice does not have dedicated resources to provide consistent meaningful service in accordance with CMS requirements patients will not find the program valuable and will not continue on receiving services. Therefore, it is important once chronic care management services are consistent and provide value to the patient. Otherwise, the cost to on board a patient will not be worth all the time and energy.
The reimbursement rates for Medicare CCM services differ depending on the level of service provided and the geographic region of the provider. However, in general, providers can expect to receive between $60 and $140 per patient per month for Medicare CCM services. This significant amount adds up to providers’ revenue who have a large patient population with chronic conditions.
In addition to the financial benefits, CCM will help providers to improve patient outcomes, patient satisfaction, and cut overall healthcare costs for the patient. By providing these non-face-to-face services the patient is more engaged with their care by being more informed about their health which prevents complications, unnecessary ER visits and hospitalizations,
However, it is important to note that carrying through a successful CCM program demands an investment of time and resources, including staff training, patient education, auditing, and the development of documentation protocols and comprehensive care plans Providers should consider all the costs and benefits of CCM before executing a program in their practice and decide if they would like to hire additional clinical staff, outsource the clinical staff or do a hybrid model care organization.
What is Wagner’s Chronic Care Model?
Wagner’s Chronic Care Model was developed to deliver patients with chronic conditions high-quality care and is used in healthcare systems worldwide.
The model is based on the premise that chronic disease management needs a proactive, patient-centered approach that involves multiple stakeholders, including healthcare providers, patients, and community resources. The model consists of six key elements:
- Health System Organization: The model stresses the importance of restructured healthcare delivery systems to better assist chronic care management. This includes ensuring access to appropriate coordinated care for patients across providers and settings, and healthcare providers are properly trained and have resources to manage chronic conditions effectively.
- Delivery System Design: To meet the needs of patients with chronic conditions, the model discusses the need for the healthcare delivery system to be designed based on the needs of the patients with chronic conditions. This involves using evidence-based guidelines, developing care management protocols, and supporting care coordination across care settings.
- Decision Support: The model discusses the importance of providing healthcare providers with the tools and information they need to make well informed decisions about patient care including: giving access to evidence-based guidelines, decision support tools, and patient registries.
- Self-Management Support: The model is focused on empowering patients to manage their own health. This involves educating patients with skills and to self-manage their conditions and provide them with support systems and community resources.
- Clinical Information Systems: The model emphasizes the importance of using chronic care management technology such as: electronic health records, chronic care management software, decision support tools to providers, and using patient registries to oversee patient outcomes.
- Community Resources and Policies: The model engages policies and community resources and policies to support chronic care management. This includes working with community organizations to create support programs for patients, and be an advocate for policies that support chronic care management.
