Chronic conditions are long-term illness such as cancer, diabetes, chronic bronchitis, congestive heart disease depression, asthma, cirrhosis of the liver, hypertension etc. which requires an extended period of care.

The Chronic Care Management at CMS is intended to provide 20 minutes non face-to-face services for patients suffering from two or more chronic conditions by providers, they can either use mHealth or telehealth technology to fulfill the CCM criteria.

CMS has emphasized the importance of care in population health. From 2015, it has started to pay Medicare providers for providing CCM service of 20 minute for 30 day calendar month. Under CPT code 99490, eligible providers are paid $42.60(average) per Medicare patient only to those patients who have agreed to pay 20% co payment.

The reason behind this payment is to improve the wellness of the people. Increase in the number of chronic diseases and poorly coordinated US healthcare system makes chronic care patients to suffer. It is estimated that by 2030 half of the US population might have more than one chronic conditions. After providing this extended care service, healthcare has seen a significant improvement in care. Offering aftercare service post hospital visits shows positive results in health outcomes.

CCM scope of service
The CCM service includes a recording of patient health data, an electronic care plan, access to care management services, managing transitional care, and coordinating and sharing patient information.

1. The structured way of recording data
A patient record should contain details of demographics, problems, medications and medication allergies in a structured clinical summary record using certified EHR technology.

2. Creating e-care plans
a. A patient-centered care plan is created based on a physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient.
b. Any modification in care plan should be recorded and updated in the patient medical record.
c. Ensure this care plan can be accessed by any physician inside and outside the network.

3. Access to Care Management services
a. 24/7 Service
Giving 24/7 service a day in per calendar month for patients to make timely contact with health professionals during or after emergency.

b. Care Continuity
A patient can communicate with care providers, make successive routine appointments easily and also get suggestions or advice on medications via telephone, secure messaging, or video calling.

4.Manage Care
Care Management Service includes a systematic way of assessing patient needs, system-based approach to billing process, and medication reconciliation.

5. Managing care transitions among providers
With the use of electronic medical records, it is easy for providers to make quick referrals and follow up process during and after an emergency with skilled nurses, and practitioners.

6. Coordination
CCM services also help to coordinate with home and community based clinical facilities by sharing patient data with providers and practitioners outside of the network.

Documentation/ Billing
Each practice will have its own system of documentation for billing. 20 minutes of non-face-to-face service should be taped in a more detailed form, including caregiver name, time logs, physician feedback, record changes in a care plan, and integrated with EHR.

In order to avoid duplicate payment, CMS pays Medicare providers separately for care management and CCM service as it believes that care management is an integral part of all of these services.

The CCM CPT code (99490) cannot be billed when the patient also get service under

Transitional care management codes (99495-99496)
Home or community clinical service codes (G0181-G0182)
End-stage renal disease services codes (90951-90970)

Physicians Reimbursement

CMS pointed that providers have to meet other criteria in order to qualify for CCM payments. The criteria are listed below:

1. Using certified EHR
CCM service requires the use of certified EHRs to record the services offered for future reference and documentation purposes.
EHR helps members of hospitals to access patient record at the same time. It helps them to get updated information about patient’s health issues and can give effective treatment.

2. Time spent on CCM service
If many physicians are involved in same patient’s care then each physician are paid for the time spent on care. Time logs will act as a time tracker to avoid duplicate billing.

3. Getting patient approval
To be reimbursed by CMS, patients must agree to pay $8 monthly copay. Since it is a new process and some patients may not understand why they have to pay for something they were previously getting for free.

HealthViewX CCM solution helps to coordinate better care, makes documentation work simple and time monitoring tool to help ease the process of physician reimbursement billing.

Almost half of the adult population in the US is affected by at least one chronic disease and more than half of Medicare reimbursements are spent on senior patients with more than one chronic conditions. These are not pretty statistics nor is this financially or socially sustainable.

As a response, albeit late response to this rise in cost and fall in population health statistics, CMS has devised a program to control the epidemic. The CMC Chronic Care Management program was designed to promote a ‘healthy’ and sustainable long-term care delivery model which will incentivize providers for providing care above and beyond traditional. The program will identify patients with more than one chronic condition as it is defined by CMS and will provide care as these patients have the most risk and thus the most expensive to treat.

It has been little more than a year and a half since this new program was introduced and yes, it is too early to evaluate. But as far as we can see the take away from the program is largely positive. Reports state that the program has been successful in increasing the patient’s participation in their health, improving patient-provider relationship and overall health outcome. Yet this might not be the right way of evaluating a program. The better way to look at this is to look at the overall picture of what the program promises not just for patients but for all stakeholders.

Chronic care management is proposed to set a new approach to healthcare and its expenditure, value-based model is taking over the fee-for-service model and is connected to provider reimbursement.

Some ‘‘other’’ benefits of CCM are as below

Reactionary care to proactive care
Beyond the four walls of a care facility
Reduce readmission chances
Promotes the use of telehealth technology
Holistic approach

1. Reactionary care to proactive care:

The use of medicine has always been more or less reactionary, healthcare did not actively participate in eliminating the chances of getting a disease or condition but always reacted to the symptoms resulting out of these diseases as it is explained by patients or observed by the healthcare professionals.
Those with multiple chronic conditions are at a greater risk of accumulating other health concerns as time progresses. Chronic care management aims to highlight this factor by looking at the overall health of the patients.

2. Beyond the four walls of care facility:

Chronic care management forces providers to look and reach beyond their office walls and provide care. It’s a conventional idea but in practice, this is rather a new concept.
For example, CCM program elements highlight that the provider or a qualified staff must contact the patient regularly for at least 20min of face-to-face care over a period of one calendar month. This is a new manner of engaging with patients for many physicians allowing them not only to look at the symptoms but sometimes be actively participating and engaging along the recovery period of the patients.

3. Reduce readmission chances:

Patients with more than one chronic conditions have a higher chance of getting admitted to a hospital than a healthy patient. For a chronic patient it is a never-ending journey to the hospital and from the hospital, not being able to put the constant shift, it gets hard to settle down post discharge. Continuous contact and monitoring of patient condition help in avoiding unnecessary readmission which not only affects the patient financially but also their morale.

4. Promotes the use of telehealth technology:

Telehealth means the use of various information technology tools to connect and contact with patients when they are geographically separated from the location of the provider or the facility. Chronic care management program promotes the use of such technologies, it has shown that such technology can improve the patient health outcomes. Such technologies need not be limited only to CCM program but can be successfully used for achieving better results with other patients in general.

5. Holistic approach

This is the whole point of the exercise, to have a holistic approach towards healthcare. CCM program aims to look at a patient as a whole rather than a list of conditions and complications. Our healthcare professionals have been doing a great job within the bounds of what they could do but with the introduction of CCM providers being incentivized to do the best they can for the health and welfare of their patients.

So, why should we care about CCM after the many acronyms that have come out before?
Acronyms proposed by many new laws and out of many agencies and they all came short of what was promised.

We should care about CCM because it is a new idea which came out of a new way of thinking, which if everything goes as well as it does on paper can positively impact the lives of many people who are forced to choose between health and financial well-being, having to watch their loved ones suffer helplessly; between pursuit of hospital bed and pursuit of happiness.