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Launching a Chronic Care Management Program: Part 1


The CMS launched CPT code 99490 for Chronic Care Management (CCM) in January of 2015. Designed to provide enhanced patient care through non-face-to-face care coordination for Medicare patients with two or more chronic conditions, the program averages a $42 per member per month reimbursement rate.So how successful has the program been thus far? CCM has achieved only moderate adoption to this point, in part due to the lack of education. Many providers simply don’t know Medicare provides reimbursement for patients with two or more chronic conditions and others often aren’t aware of the necessary components of the program. Aside from the complexity involved with caring for CCM eligible patients, challenges facing providers include:

  1. Enrollment and retention
  2. Creating efficient workflow processes
  3. Ensuring proper staffing

Let’s take this one step at a time:

What exactly are the requirements for CPT code 99490? As mentioned, the program is designated for Medicare patients with two or more chronic conditions that are expected to last more than 12 months. Those conditions must also place the patient at significant risk of death or functional decline. In order to implement the program, providers must create a care program and offer 20 minutes of non-face-to-face time every month to each enrolled patient.

Importantly, the non-face-to-face care may be administered by clinical nurse specialists, certified nurse midwives, nurse practitioners and physician assistants.

Providers you must also:

  1. Implement Certified EHR technology to collect and record patient demographics, medication and allergies and provide coordinated care.
  2. Provide patients with 24/7 access to care management services in addition to the necessary 20 minutes of non-face-to-face communication with the care team.

The actual enrollment of patients requires a provider/patient exchange of information to cover elements of service, information sharing, cost for the patient ($8/month co-pay) and how to opt out of the program. Assuming the patient is prepared to enroll, a signed agreement (including authorization for electronic communication of medical information) must be obtained and filed.

Now that the patient is enrolled, providers may deliver the services outlined above. However, in order to utilize CPT code 99490 for monthly reimbursement, you must track and document the care teams’ non-face-to-face communication with each patient prior to filing with the CMS.

Yes, there is plenty of work involved with the setup and implementation of the program, but the benefits are significant. An increase in patient satisfaction, improved disease management, decreased hospitalizations/emergency room visits/readmissions, and individual health behavioral changes make the program worth the effort. Of course, beyond enhanced patient care, there are financial benefits for the provider (500 CCM patients per year equates to $250k in reimbursement).

Next week, we will begin breaking down the challenges associated with CCM and offer insight into how to successfully launch and grow a program.

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