If you are interested in setting up a Chronic Care Management (CCM) program for your hospital or practice, here are 5 steps that take you through the process. It is the right read for someone who is convinced of the value of the program, and want an instructional post with best practices in order to create a well-rounded strategy. This article zooms out and looks at the logic of forming such a program and how one can best utilize it to generate revenue for a healthcare organization. While the 5 Steps offers guideposts on how you should set up your CCM program, this post answers why you should do it and how exactly you can extract value from it. Guidelines do a great job of showing how to set something up, but not necessarily demonstrate the urgency of the situation. I hope this post shows you the significance of a CCM program, and how not to leave money on the table, especially where there is value to be added.
Why Act Now?
Before anything else, patients need care now, not later. It’s a part of demand-side economics.
While chronic conditions by definition cannot be cured by medicines or vaccinations, they can be managed, hence why we use the term “management” in Chronic Care Management. But time is critical, because if chronic conditions are left unmanaged, then they can put the patient at risk of serious exacerbations, leading to a permanent decline of health and even death. The nature of chronic conditions is such, that if left unmanaged, they continue to worsen the health of the affected patient. Hence time is of the essence, as the earlier one gets diagnosed and starts treatment, the likelihood of a positive outcome is higher where the patient has a higher quality of life via:
- Increased mobility, flexibility, endurance and strength
- Pain reduction
- Better Sleep
- Stress Reduction
If left too late, the likelihood of the patient returning to pre-chronic condition lifestyle is reduced. As stated before, the health condition changes brought about by chronic care tends to be extremely sticky. That is, if there is a regression of health, it is more difficult to reverse the downward trend. On the other hand, if detected early and managed properly, the patient need not ever regress and keep all the symptoms at a manageable level. Hence, they can resume living a normal life.
What’s in it for the Doctors?
While more patients are set to clamor for chronic care, how are doctors looking at the situation?
Firstly, physicians are bound by oath to apply all measures that are required for the benefit of the sick. They are supposed to avoid the twin traps of therapeutic nihilism or overtreatment. In other words, they should not do too much, nor too little, but do as needed to the best of their knowledge. Given the knowledge of chronic conditions on their long-standing and recurrent nature, physicians must then act as early as possible to keep any chronic condition at a manageable level. Overtreatment is not as much of a concern here as therapeutic nihilism.
Secondly, the whole healthcare model is undergoing a massive shift right now, from volume-based reimbursements to outcome-based reimbursements. But there is some friction, as the popular Fee for Service Model (FFS) is not ready to be displaced just yet with alternative payment models. But the introduction of CPT codes to manage chronic care has provided the perfect transition opportunity for providers and hospitals alike. They can still bill for services and hence generate revenue from The Centers for Medicare & Medicaid Services (CMS). But the care that is provided is based more on outcome or value, and less on volume. This is because most of the CPT codes (more on that later) are capped for one-time use per month, with the exception of a few codes for complex care patients, who require multiple care episodes in the same month. So it kind of resembles a capitation model, where a certain amount of funds are allocated for every patient to ensure their care, in this case, their chronic care. Thus, even though there is still monthly billing (submitting monthly claims is better), the chronic care patients develop a relationship with their care providers that extend beyond just a service. It adds value to their lives monthly.
What’s in it for the Hospitals?
While patients and physicians can work out a system by which to receive and provide care respectively, is there enough impetus for change at the organizational level?
Hospital executives live and die by performance metrics. They want to reduce readmissions, reduce length and cost of stay, and increase throughput. All of those things are achieved by running a thriving chronic care program. Treating patients remotely in the vicinity of their homes ensures that there is no unnecessary resource utilization, and that there is capacity to treat new patients. The change in demographics to a more elderly population, most of whom are afflicted with chronic diseases, mean that there will be no shortage of demand. More than three quarters of Americans aged 65 and older suffer from more than one chronic disease, thus making them eligible for the chronic care program. If such a segment of the population is to be treated, it cannot be done so in inpatient settings without sacrificing numbers from all other metrics. Outpatient care development thus, has come to forefront as an impending strategic initiative that many are still hesitant on. It is up to strategy makers to decide how to deal with this wave. Starting a CCM program would be an excellent first step.
How to Begin? (Avg. National Reimbursement Figures at the End)
First, one has to decide which payment models they want to participate in. As stated before, one can use the CPT codes that are listed by CMS to treat chronic care. They allow physicians to be reimbursed for every service, while providing much needed valuable care to the patient, which they would have had to avail from somewhere or face serious health hazards. But if one is inclined to focus more on the value provided, and tie reimbursement to outcome, then there are multiple value-based payment models available. If one wants to further zero in on value, they can offer emerging programs such as urgent centers and minute clinics, which have become trends in healthcare, but which lead to greater health and loyalty among patients. This post focuses on the FFS Model.
Early diagnosis is the best scenario, and the best way to do this would be through preventive wellness programs. The Annual Wellness Visit (AWV) is one such program that is 100% covered by CMS. It includes a Health Risk Assessment which reviews everything from family medical history, to prior hospitalizations, medications, allergies, preventive tests and screeners. It also includes an Activities of Daily Living Review which assesses the patient’s ability to eat, bathe, dress, go to the toilet, get in and out of bed and maintain bladder and bowel functions. Thus, one can see that an Annual Wellness Visit is well equipped to detect any deterioration of health on the part of the patient, and judge if the condition is chronic or not. It is well placed to detect the symptoms of chronic conditions and admit the patient into a chronic care management program.
G0438 initial visit ($164)- For new first time patients who have been enrolled with Medicare for more than one year.
G0439 subsequent visit ($109)- For returning patients who have had the AWV before. A patient is only eligible for a subsequent visit a year after the initial visit.
How to Administer? (Avg. National Reimbursement Figures at the End)
At the very minimum, there must be 20 minutes of non face-to-face outreach care provided to chronic patients every month. It is helpful to create a care plan as to what such outreach could entail. Though the patient’s condition will be the best arbiter of next steps, especially if they are part of a remote patient monitoring (RPM) program. But it helps to have care plan ready that details the standard procedures, such as the medium of outreach (email, text, phone call, video call), and the bulletin of discussion points which can include care plan adherence, medication management, pain management etc.
Ensure there are new enrollees into the program, and that they are satisfied with the service that is being provided. Starting a CCM program is not a onetime activity, but rather it has to be monitored on a timely basis to ensure that it is growing sustainably and satisfying patients by providing the type of care that is needed. As it’s a new line of service for a hospital or physician practice, its metrics need to be monitored just like all other lines to account for its existence and future growth. One important qualitative metric to measure is patient engagement. High patient engagement is a sign of high satisfaction and adherence to medication and care plans as well. Ideally, if possible, you do not want CCM programs to be a hassle for the patient. One of the pluses of electronic communication is that two-way communication is more frequent but less time intensive, and thus it builds a greater rapport between patients and providers where no time is wasted. The patient is able to keep in touch at their own leisure, but providers are able to enforce the care plan as well through e checkups, reminders, vital signs monitoring etc.
Check with commercial payers. There are plenty of chronic care patients under 65 who are privately insured. Similarly, there are people over 65 who choose to stay with their original insurance plan and not make the switchover to Medicare. Commercial payers offer higher reimbursements and have laxer requirements than CMS, so it is a great market segment worth exploring. Once you have your CCM program infrastructurally set up with properly trained staff, you can provide the same service to both government and private payors.
Integrate CCM with RPM. RPM software helps not only helps with structured reporting of each patient, but also reduces in person visits by monitoring data from wearable devices. Integrating wearable devices help track patient data in real time, and thus provides tremendous additional value to an already valuable CCM program. In fact, it can be argued that without RPM, a CCM can only receive communicational benefits, such as being alert to the patient’s condition, sharing and revising care plans, sending medication reminders, etc. A RPM program already consists all of these best in class features, but it also collects and monitors patient data. It thereby does not need to rely on just communication (which can be hindered by lack of articulation or bias), but on the actual patient data which can be used to change care plans, prescribe new medicines, intervene and triage as necessary. It makes the CCM program more complete.
Further Case for Adding a RPM Component to CCM
CCM is a great opportunity to not only improve individual health, but population health as well. Especially if the patient body of chronic cases is sufficiently large for that hospital or practice. Hence, there is a scope of utilizing the large amounts of data generated for analyzing population trends, and make decisions accordingly at a population level. But in order to generate such volumes of data, a monthly electronic checkup simply won’t suffice the 3Vs of big data. Volume, variety and velocity. But if the CCM program is fitted with a RPM program, then multiple vital signals(variety) can be monitored in real time(velocity) from each patient, which amounts to a lot of data at a population level (volume). Thus, each patient can have a tailored care plan based on real time data, intervene before potential emergency situations, and recommend new actions based on other similar cases. It makes any CCM program that much more powerful because of the capability to diagnose, treat and manage chronic diseases for the long term.
Also, speaking from a business perspective, remote patient monitoring has its own CPT code, which can be billed in the same month as any CCM code. CMS recognizes that equipping a CCM program comes with costs that do not overlap with costs required to run a CCM program. Hence, they have created CPT codes that specifically allow one to be reimbursed for providing RPM. Thus, both RPM and CCM can be billed in the same month due to their complementary nature, but the time allocated for one cannot be attributed to another, that is, no double counting. Like CCM, a provider must acquire patient consent and document it in the patient’s medical record. Also, just like CCM, new patients or patients not seen by the practitioner within the last 12 months, must first be inducted into the program by a face to face initiating visit. One more similarity of RPM with CCM is that it is not considered a telehealth service, and for that reason the patient beneficiary does not need to be in a designated originating site. Such shared characteristics make for an ideal partnership between RPM and CCM, where the core service provided is so closely tied with remote delivery, that its remote aspect does not automatically categorize it into the telehealth bin.
Ideally, the condition of the patient will tell you which is the appropriate CPT code to use, as besides Complex CCM codes, none of the other CPT codes can be:
1) Billed in the same month as each other.
2) Billed more than once.
As a starting point for new patients, one can use either CPT Code 99490 or 99491.
CPT 99490 ($42 for non-facility/ $32 for facility) “Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Assumes 15 minutes of work by the billing practitioner per month.”
CPT 99491($84 for non-facility and facility) “Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.”
For more complex cases
CPT 99487 ($93 for non-facility/ $53 for facility) “60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Needs establishment or substantial revision of a comprehensive care plan, with moderate or high complexity medical decision making.”
CPT 99489 ($47 for non-facility/ $27 for facility) “Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).”
There are two ways how one can be reimbursed for RPM services.
CPT code 99091($58 eligible in both non facility and facility): “Collection and interpretation of physiologic data (e.g. ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.”
CPT code 99453 ($19): “Remote monitoring of physiologic parameter(s) (e.g, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
CPT code 99454 ($64): “Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
CPT code 99457($52 for non-facility/ $32 for facility): “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
The lower price tag on CPT 99457 is because it requires at least 20 minutes of care per calendar month, as opposed to at least 30 minutes of care per 30-day period in CPT 99091. The calendar month cycle is said to be better for record keeping than the 30-day period. Submitting claims is easier on a monthly basis.
CPT 99457 can be furnished by clinical staff, in addition to physicians and qualified health professionals. CPT 99091 had only mentioned the latter two groups on eligibility. Thus CPT 99457 is more flexible on who can management the treatment.
There is currently a difference in supervision requirements between RPM and CCM. CCM allows incident to billing under general supervision, where the physician and auxiliary personnel do not have to be in the same building at the same time. Thus qualified medical professionals in charge of billing can also be reimbursed at the same rate as physicians. On the other hand, RPM requires direct supervision. There is no Incident to Billing without direct supervision.
For Value-Based Payment (VBM) Models
Switching to VBM models should not be ruled out. All those who participate in it report greater outcomes, and 63% of all reimbursement is now non-FFS based.
If you are going to participate in value-based programs, adopting a data centric approach is a must. Everything must be documented, from admissions, to processes, to outcomes. Such stringent documentation practices help organizations to quantifiably demonstrate the value of care that is provided in terms of improved outcomes. It is imperative that one’s EHR system is set up to capture and track all metrics. Improving data interoperability is also crucial when participating in value-based payment models. In healthcare, there are different silos of information which are often disconnected from each other. Such fragmentation leads to a discrepancy between the best course of action versus the one that is actually implemented due to the lack of access to patient data.
It is important to review strategy as to how one can run a chronic care program that is financially sustainable, which is why reimbursement calculations are such a big deal. But on the clinical aspect, there is something called the Chronic Care Model, which is an organizational framework for treating chronic care patients in a primary care setting. If you have ambitions of transitioning to a value-based payment model some day from a strictly FFS model, then following the Chronic Care Model can be helpful. It is an evidence-based approach that was designed to improve both systematic and individual chronic care.
I hope you found this post helpful in understanding the need for CCM, and the different ways to be reimbursed for CCM and RPM in the FFS model. As stated in the paragraph before, VBM models should be explored as well. Fortunately, the options for reimbursements in VBM are not as rigid as FFS. But as long as FFS exists, people must utilize it to grow their service lines.
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