Chronic Care Management

Chronic Care Management

The U.S. healthcare system is in the midst of a major transition. One of the major agents for change is the utilization of primary care. Primary care has always been important, but it’s becoming an increasingly important piece in our healthcare system due to: the aging of our population, the increase in chronic disease, attention on preventive services, care coordination, and cost savings. We say it’s about time.

Traditionally, most physician offices have had little financial incentive for non-face-to-face services.

But, in January 2015, Medicare began separately reimbursing qualified organizations for Chronic Care Management (CCM) services. Primary care physicians are expected to utilize the CCM code the most, but specialists meeting the CCM requirements will also be able to bill for their non-face-to-face services.


What is CCM?

CMS defines CCM as at least 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified healthcare professional (hint: this part will be important), per calendar month with the following elements:

Non-face-to-face clinical staff time can be accomplished by phone call or through electronic communication for care coordination, medication management, and 24/7 accessibility.

Clinical staff members are eligible to do the actual work, but they cannot bill directly to Medicare. “A clinical staff member is a person who works under the supervision of a physician or other qualified healthcare professional... medical assistants, licensed practical nurse, registered nurse, etc.”

Clarification: CMS uses the word “physician” when they define who is eligible to bill for CCM services, but billing is not limited to just physicians. Physician assistants, nurse practitioners, certified nurse midwives, and clinical nurse specialists are all eligible to bill, but only one practitioner can bill for CCM service per patient per month.

The average reimbursement amount is $40.00 per patient under the 99490 CPT code. Qualified healthcare professionals can bill this code one time per month, per patient.


Which patients are eligible for CCM?

  • Patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline

  • Comprehensive care plan established, implemented, revised, or monitored


Do you have what it takes to provide and bill for CCM Services?

  • Documentation of patient demographics, problems, and medical history must be completed using a certified EHR system;

  • Create and share with patient and patient’s specialists, a patient-centered care plan based on physical, mental, cognitive, psychosocial, functional, and environmental assessment;

  • Provide 24/7 contact availability to a provider in the practice who can address the patient’s urgent chronic care needs;

  • Manage patient referrals and care transitions between providers

  • Documentation of time spent providing CCM services per month

If you’re PCMH or PCSP Recognized, you’re likely meeting a number of the requirements necessary for CCM eligibility. To learn more about CCM eligibility click here.


Why is Medicare willing to pay for CCM?

Well, chronic diseases are complicated to manage and VERY expensive.

  • Over ⅔ of Medicare beneficiaries (21 million people) have 2+ chronic conditions, and at least ⅓ (11 million people) have 4+ chronic conditions.

  • The ⅔ of beneficiaries with 2+ chronic conditions accounted for 93% of medicare spending

  • The aging population, and the prevalence of multiple chronic conditions significantly increases as beneficiaries age

  • Chronic diseases stretch across all demographics, it’s not just one population

  • Most common chronic diseases of Medicare beneficiaries include: hypertension, high cholesterol, diabetes, and heart disease


Market Adoption

CCM reimbursements from Medicare have been available since 2015, but in our experience many practices aren’t taking advantage of it- major bummer.

CMS recently reported that about 35 million Medicare beneficiaries are eligible to receive these billable care-management services, but the agency has received reimbursement requests for only about 100,000. Wow.

It may sound complicated, but meeting the CCM requirements may not be as difficult for you as it may seem. As we mentioned earlier, if you are PCMH or PCSP Recognized, billing for CCM should be a no brainer.

Per Andis Robeznieks, “Medical home practices are at an advantage in meeting the care-management requirements, which include obtaining patient consent, recording data in a standardized format, and creating a care plan with an expected outcome, measurable goals, and strategies to manage symptoms and medication.”

Billing for CCM is a great step forward because physician offices can begin to be paid for chronic care management and follow-up activities. Many practices do this without being reimbursed for it, and hopefully more will begin to do these activities now that there is reimbursement available.

CCM allows for care management by telephone or electronic communication while also allowing physicians to bill for non-face-to-face care. This is one more step in the right direction to reward physicians for managing the health of their patients.


Contact us at Clarify for advice or questions regarding CCM and ways we can work together.


Additional Resources Clarify recommends:

American College of Physicians breakdown on CCM

DHHS: Chronic care management services

Sources: CDC, Federal Register, CMS, American College of Physicians, Modern Healthcare, Optum360