Chronic Care Management Basics—What You Need to Know

In 2015, the Centers for Medicare and Medicaid Services launched its Chronic Care Management initiative, which allows practices to bill Medicare separately for coordinating chronic-care services for patients with two or more chronic conditions. A CMS report released in early 2018 found that while its CCM program was working (per-beneficiary spending dropped 15% between the first and second year of the program), too few providers were taking advantage of the program. In its first two years, only 684,000 beneficiaries received CCM services despite the fact that about 35 million Medicare participants were eligible.

CMS said low uptake was caused by confusion over billing codes. Providers, meanwhile, shared stories at town hall meetings about pushback from patients unable to pay the 20% co-insurance. Providers also pointed out that reimbursement was too low, especially for the most complex cases. In 2015 and 2016, a single CCM code paid approximately $42 per patient per month. Beginning in 2017, additional codes were added to address the provider concerns, with payments ranging from $43 to more than $141, depending on the complexity of the case.

Interested in implementing CCM in your practice? Here’s what you need to know to be able to implement and bill CCM codes.

What’s included in CCM?

CMS defines CCM as non-face-to-face services, including communication with the patient, community resources and other health professionals for care coordination (both electronically and by phone), medication management, and providing the patient with access to communication and care 24/7.

Another key component of CCM is the creation of a patient-centered plan of care based on a comprehensive assessment, with updates as appropriate.

Who can provide CCM services?

CCM is provided under the direction of the patient’s physician or non-physician practitioner using a team-based approach to care. The clinical staff in the practice performs the care coordination and works directly with the patients.

Nonphysician practitioners include a physician assistant, nurse practitioner, clinical nurse specialist and certified nurse-midwife. While multiple clinicians might be involved in this chronic care, only one can bill for CCM each month. As a result, the billing provider is typically the clinician who provides the majority of the care, such as the primary care provider (PCP).

What patients are eligible for CCM?

Medicare beneficiaries are eligible to receive CCM services if they have two or more chronic conditions expected to last at least 12 months or until death. If these conditions are left unmanaged, they will place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

What are the CCM billing codes?

There are separate codes for CCM and Complex CCM plus an add-on code that helps compensate for the most complex cases. See table below (Source: CMS Chronic Care Management Service Changes for 2017).

What are the technology requirements?

Previously, participating providers had to use CMS-certified EHRs for CCM documentation and transitional care management documents, but that changed in 2017. A certified EHR is still required to record core clinical information, such as patient demographics, medications and allergies. Additionally, there is no longer a specific technology requirement for sharing care plan information with other parties, which was a concern of small and rural practices that have yet to adopt EHRs. They can use fax and even mail, as long as the information is shared in a timely fashion.

What else do we need to know?

Your practice must have the patient’s consent in order to start billing for CCM services. Oral consent is fine, as long as you’ve documented it.

Additionally, it’s a good idea to point out to patients that they’re responsible for 20% co-insurance on any CCM services. If they have supplemental insurance or Medicaid, it’s possible that would be covered.

CCM also has a long list of documentation requirements, so it’s a good idea to familiarize yourself with the rules. The CMS Chronic Care Management Services Fact Sheet is a great place to start. You can also check out these HealthTechS3 webinars on the topic: What’s New in the 2018 Regulations for CCM? Understanding the Alphabet Soup of Care Management and Adding Behavioral Health to Your Chronic Care Management Program.

Does your practice need help getting a CCM program off the ground? HealthTechS3 can help you implement and bill CCM codes. For more information or to get started, email Faith Jones, MSN, RN, NEA-BC, director of care coordination and Lean consulting at faith.jones@HealthTechS3.com.