Chronic care management: Implementation and reimbursements

Abstract

Quality measures are tools that help measure healthcare processes, outcomes, patient perceptions, and organizational systems, with the ability to provide high-quality healthcare. These goals include effective, safe, efficient, patient-centered, equitable, and timely care.  Thus, the Centers for Medicare & Medicaid Services (CMS) launched the Chronic Care Management (CCM) program in 2015, compensating providers for time spent managing complex patient conditions beyond the clinic. Understanding the utility, implementation, and trends of CCM may be key to fostering the Quadruple Aim of improving healthcare quality further.

What is CCM?

The CCM program began in 2015 with a set of reimbursement codes so that hospital systems and/or providers may bill for time spent beyond the clinic managing patients with complex conditions.¹ This time is often spent outside the clinic, and includes monthly calls with patients in which the providers discuss patient needs, medication use and adherence, preventative services and more.

Analogues of the CCM program include remote patient monitoring (RPM), principal care management (PCM) and transitional care management (TCM) intended for specific use cases in line with out-of-clinic activities that require reimbursement. CCM stands apart in that it requires that a patient must have two or more chronic conditions that will last 12 months or more.² The list of chronic conditions that meet this criterion is expansive but includes conditions such as diabetes, asthma, arthritis, COPD and depression.³

CCM can help us achieve the Quadruple Aim in healthcare of improving the patient experience, improving population health, reducing costs, and improving the lives of healthcare providers and staff. Quality measures can be better attained on CCM calls by instating standard orders for screenings such as mammograms, colorectal cancer screening and bone density screening. Revenue generation in the form of incentives can also be attained, helping healthcare entities achieve quality measures and potential further income generation.

Fragmented care costs more than $75 billion annually, something that CCM can address by better coordination of healthcare resources.⁴ Costs aside, participating patients note the benefits of the program — better coordination, continuity of care and access to the primary care team.⁵

Implementation of CCM

A few standards exist for the implementation of CCM with a patient. Before billing CCM, the patients must have had an initiating visit within the past year. The practitioner must discuss CCM with the patient during the initiating visit, otherwise the visit will not be valid as the initiating visit. Consent must be obtained to begin, and it may be verbal or written. Patient health information (PHI) must be recorded using an EHR system that complies with the latest EHR incentive program from Medicare. CCM requires that:

• Each patient has a comprehensive care plan provided that addresses his/her conditions.
• Patients must be able to contact a provider at all times of the day if calling urgently, such that urgent health concerns may be addressed.⁶

The initiating visit may be separately billed, as it is not a part of CCM.⁷ Billing practitioners may apply HCPCS code G0506 (once) if they personally perform care planning activities upon the initiation of CCM; upon initiation, CCM services may be billed monthly.⁸

Physicians — specialists and primary care practitioners — and some advanced practice providers (APPs) (e.g., clinical nurse specialists, nurse practitioners, physician assistants, and certified nurse midwifes) may bill for CCM; only one provider may furnish and bill for CCM for a patient in a month.⁹

CCM can be billed as complex or non-complex. Complex CCM is defined as management provided for a moderate to highly complex patient under the usual CCM rules, for a period of 60 minutes (CPT® code 99487). Modifiers exist in CCM coding that allow for the billing of additional time. For complex CCM, CPT® code 99489 may be applied for every 30 minutes of additional time spent with the patient. Non-complex CCM is billed with code 99490 for the first 20 minutes and can be extended with code 99439 for every additional 20 minutes. Extensions on non-complex CCM can only be granted twice per month. It is important to realize that non-complex and complex CCM may not be billed together.¹⁰

Implementation of CCM may be outsourced to a third party, often on a commission basis, or done in house with additional staffing. A study estimated that it would take a practice 131 patients to recoup costs associated with hiring staff to perform CCM activities full time.¹² This number is subject to change, as CCM has expanded complex management since this initial estimate. Properly determining the viability of the program requires considering an array of factors, such as eligible patient populations, patient finances (as previously stated, patients are more likely to enroll if they do not have out-of-pocket costs), level of staffing for program implementation, and geographic location (for Medicare billing reasons).

CCM trends and discussion

Adoption data for CCM is scarce but insightful. A year after the introduction of CCM, a study noted that adoption rates were about 6.47 patients per eligible 1,000 in the New England region.¹³ Overall, CMS reports the accepted number of CCM services grew from 996,162 in 2015 to 11,769,335 in 2018, and accepted payments grew from $40,672,015 in 2015 to $504,478,733 in 2018.¹⁴ The same study noted that in that period, approximately 5.4% of all CCM claims were denied in 2018. Denial rates are a possible factor in adoption prevention.¹⁵ CCM adoption may be further hindered by a lack of provider awareness and financial startup costs.

CCM continues to evolve with time. Other programs (such as RPM, TCM, and PCM) have also established niches in rewarding providers for other out-of-clinic efforts and are worth investigating alongside a CCM implementation as supplemental revenue streams. While it is difficult to predict the future of the CCM program, it certainly reflects the larger trend of healthcare moving to better quality metrics in a multifaceted, patient- and team-integrated approach.

Notes:

1. CMS. “Chronic Care Management Services.” MLN Booklet 909188. September 2022. Available from: https://go.cms.gov/2XSHVpH.
2. Ibid.
3. Ibid.
4. Bodenheimer T, Sinsky C. “From triple to quadruple aim: care of the patient requires care of the provider.” Ann Fam Med. 2014 Nov-Dec;12(6):573-6. doi: 10.1370/afm.1713. PMID: 25384822; PMCID: PMC4226781.
5. Wilson C, O’Malley AS, Bozzolo, C, McCall N, Ma S. (2019). “Patient Experiences with Chronic Care Management Services and Fees: a Qualitative Study.” Journal of General Internal Medicine, 34(2), 250–255. https://doi.org/10.1007/s11606-018-4750-x.
6. CMS.
7. Ibid.
8. Ibid.
9. Ibid.
10. American Academy of Family Physicians. (n.d.). Chronic Care Management. Retrieved April 6, 2023, from https://bit.ly/3ME8ewp.
11. CMS. “2022 Medicare Physician Fee Schedule: Understanding the Searchable Schedule.” Available from: https://go.cms.gov/3BDnNhv.
12. Reddy A, Marcotte LM, Zhou L, Fihn SD, Liao JM. (2020). “Use of Chronic Care Management Among Primary Care Clinicians.” Annals of Family Medicine, 18(5), 455–457. https://doi.org/10.1370/afm.2573.
13. Gardner RL, Youssef R, Morphis B, DaCunha A, Pelland K, Cooper E. (2018). “Use of chronic care management codes for Medicare Beneficiaries: a missed opportunity?” Journal of General Internal Medicine, 33(11), 1892–1898. https://doi.org/10.1007/s11606-018-4562-z.
14. Reddy.
15. Gardner.