Value in Managing Chronically Ill Patients

By | July 18, 2018

The Center for Medicare and Medicaid Services (CMS) launched the Chronic Care Management (CCM) program in January 2015. The introduction of CPT code 99490 allowed provider led teams to remotely manage the health of their sickest patients. Medicare fee-for-service beneficiaries with two or more chronic conditions among the twenty seven outlined by CMS (source) may be enrolled, after receiving the patient’s in-office consent, to have their regular appointments supplanted through a minimum of twenty minutes of phone or email correspondence with a nurse or other licensed practitioner. Conversations may include verification that the patient is taking their medication as prescribed, monitoring the weight of patients with Congestive Heart Failure (CHF), and many other chronic conditions that can be easily monitored remotely. Nurses may call the attention of the patient’s provider on an ad-hoc basis for remote management or the need for an in-office visit.

After enrollment in CCM the expectation is set for the development and analysis of a personalized care plan at least once per year with the patient. Patients will receive, at a minimum, twenty minutes of non-face-to-face care coordination and management per month, each month, as long as the patient is enrolled in CCM. These non-face-to-face services may be rendered by Registered Nurses, Licensed Practical Nurses, Medical Assistants, or other qualified medical personnel in conjunction with general oversight by the prescribing physician.

In 2017, CMS expanded the scope of CPT code 99490 (source). Previously, in-office consent was required of each new enrollee into CCM. CMS determined that telephonic enrollment of patients seen by the physician responsible for CCM services may be appropriate if in-office contact had occurred in the previous twelve months. In addition, CPT codes 99487 and 99489 were introduced to reward providers giving extra attention to the most ill CCM enrollees. “Complex CCM” was introduced for patients requiring at least 60 minutes of monthly CCM services. The last expansion introduced in 2017 was G0506 which rewarded billing practitioners who committed a new CCM enrollee after an in-person office visit. A non-exhaustive, illustrative list of CMS CCM enrollment practices and services rendered scenarios, applicable billing code(s), and reimbursement amounts can be found in Exhibit A.

There are notable restrictions concerning the frequency CCM codes may be charged and limitations around what other services may be provided concurrently. A complete list of exclusions can be found on the CMS website.

The rollout of CCM involves rigorous management of 6 key areas. Eligible patients must be rapidly identified and enrolled via analytical processing of insurance information, diagnosis of multiple, CCM eligible chronic conditions, and the existence of a recent appointment with the prescribing physician. Program information and enrollment teams must be developed. Appropriate technology preparedness will allow operational workflows to be easily supported by essential staff and physicians. Revenue cycle teams must coordinate coding and billing to establish that appropriate CPT and G-codes are dropped when qualifying services are provided and omitted when exclusionary criteria have been met. Optimal care management integration requires the development and implementation of a thorough operations playbook to facilitate efficient care delivery. Regulatory and compliance standards must be met to enable proper patient consent standards are met. Project management channels must be established to monitor execution, training, and program value.

There are challenges that may occur during the implementation of CCM. Many healthcare systems may not have the technological builds in place to support CCM enrollment, documentation, and billing regulations and requirements. Large EHRs provide ‘out-of-the-box’ solutions that can be purchased and are continually maintained and updated to comply with new rules and regulations. In an RVU based reimbursement model providers may lose patient volume. Various methodologies may be crafted to pool a percentage of CCM reimbursements into provider compensation.

CCM helps to address the patient’s overall health by managing and improving chronic conditions. Focused, remote care will decrease unnecessary ER visits and inpatient stays. Studies have shown that remote care management services have measurable success concerning patient satisfaction, patient ownership of care, improvement in utilization of preventative services, and stronger health outcomes (source). Diabetic patients saw marked improvements in HbA1c levels, decreased hospital and outpatient clinic use, and shorter inpatient stays (source). Several key aspects of CCM closely resemble effective processes utilized in Medicare Advantage including: initial in-person visit to assess the patients’ health, creation of individualized care management plans, and remote nursing staff to manage patient needs (source).

Reinvestments made in preventative treatments reward effective primary physicians who proactively manage their patient’s health. Near term benefits can generate over $10 million per 100,000 patients enrolled in CCM every three years while long term application of CCM builds the foundation for shared savings and other value based arrangements.

The future state of CCM supports the Patient Centered Medical Home (PCHM) model. Healthcare systems invest in thorough, patient-centered coordinated care models that provide easily accessible, high quality services to patients. Systems that have invested in CCM are at the forefront of providing a continuum of care, rather than simply managing episodic based inpatient stays, to their patients. As CCM expands commercial and government payers may provide reimbursement to patients who are chronically ill but are under 65 years of age. Many on-going conditions, such as various cancers and pregnancies, may soon have advanced preventive service models. Approximately one year ago, CMS announced the January 1, 2018 widening of the Medicare Diabetes Prevention Program6. This marked the first ever expansion of a CMS preventive service, opening the door for further development and expansion of future preventive programs.

About the Author: Colin Gibbons, MHA is an Experienced Associate Consultant at PricewaterhouseCoopers LLP in Boston, MA. He can be reached at

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