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Principal Care Management vs. Chronic Care Management: What’s the Difference?

Introduction

Medicare, the federal health insurance program primarily for individuals aged 65 and older, offers a variety of programs to help manage and coordinate care for beneficiaries. Among these are the Principal Care Management (PCM) and Chronic Care Management (CCM) programs under Medicare Part B. Both programs aim to enhance the quality of care for patients with chronic conditions, but they differ in their focus, requirements, and benefits. In this blog post, we’ll explore the key differences between PCM and CCM, providing a detailed understanding to help beneficiaries and healthcare providers navigate these options effectively.

Overview of Principal Care Management (PCM)

Principal Care Management (PCM) is a relatively newer initiative under Medicare Part B, designed to provide focused care management services for patients with a single high-risk chronic condition. The primary goal of PCM is to help patients manage their condition more effectively, reducing the need for hospitalization and improving their overall quality of life.

Key Features of PCM:

Single Chronic Condition Focus: PCM is specifically targeted at patients who have one complex chronic condition that requires intensive management. Examples include conditions like advanced heart disease, severe asthma, or complicated diabetes.
Comprehensive Care Management: PCM involves comprehensive care planning, including regular follow-ups, medication management, and coordination with other healthcare providers to ensure the patient’s needs are met.
Eligibility Requirements: To be eligible for PCM, patients must have a single high-risk chronic condition that is expected to last at least three months and poses a significant risk to their health without proper management.
Provider Requirements: Healthcare providers offering PCM services must develop and implement a detailed care plan for the patient, which includes coordination of care, monitoring of the condition, and patient education.

Overview of Chronic Care Management (CCM)

Chronic Care Management (CCM) has been part of Medicare Part B since 2015, aimed at providing coordinated care services for patients with multiple chronic conditions. The focus of CCM is broader, addressing the complex needs of patients with two or more chronic conditions.

Key Features of CCM:

Multiple Chronic Conditions: CCM is designed for patients who have two or more chronic conditions, such as hypertension, diabetes, arthritis, and depression. The program addresses the interconnected nature of these conditions and their impact on the patient’s overall health.
Ongoing Comprehensive Care: CCM includes the development and implementation of a comprehensive care plan, regular follow-ups, medication management, and coordination with various healthcare providers involved in the patient’s care.
Eligibility Requirements: Patients eligible for CCM must have at least two chronic conditions that are expected to last at least 12 months or until the end of life and pose a significant risk to the patient’s health or functional status.
Provider Requirements: Providers offering CCM services must establish, implement, and regularly update a comprehensive care plan. This includes 24/7 access to care management services, enhanced communication with the patient, and coordination with other healthcare providers.

Comparing PCM and CCM:

While both PCM and CCM aim to improve care for patients with chronic conditions, they differ in several key areas:

Focus on Conditions:
- PCM: Focuses on a single high-risk chronic condition.
- CCM: Focuses on managing multiple chronic conditions simultaneously.
Patient Eligibility:
- PCM: Patients with one high-risk chronic condition that requires intensive management.
- CCM: Patients with two or more chronic conditions that require ongoing management.
Care Plan:
- PCM: A care plan focused on managing one specific condition.
- CCM: A comprehensive care plan addressing multiple conditions and their interrelated effects.
Service Intensity:
- PCM: Provides intensive, condition-specific management.
- CCM: Offers a broader, ongoing care management approach.
Provider Involvement:
- PCM: Requires focused efforts on a single condition, often involving specialists.
- CCM: Involves coordination among various healthcare providers managing multiple conditions.

Benefits for Patients and Providers:

Both PCM and CCM offer significant benefits for patients and providers:

Improved Health Outcomes: Both programs aim to reduce hospitalizations, improve medication adherence, and enhance overall health outcomes.
Enhanced Patient Engagement: Patients receive more personalized care, leading to better engagement and satisfaction.
Coordinated Care: Providers can offer more coordinated and efficient care, reducing duplication of services and potential errors.

Conclusion:

Understanding the differences between Principal Care Management (PCM) and Chronic Care Management (CCM) is crucial for both patients and healthcare providers. PCM offers targeted, intensive management for a single high-risk chronic condition, while CCM provides comprehensive care for patients with multiple chronic conditions. By choosing the appropriate program, patients can receive the tailored care they need, improving their quality of life and health outcomes. Healthcare providers can also benefit from these programs by offering more coordinated and efficient care, ultimately enhancing patient satisfaction and reducing healthcare costs. For more details, contact info@healthviewx.com.

How HealthViewX is Revolutionizing Transitional Care Management for US Providers

Transitional Care Management (TCM) is a critical component in ensuring seamless post-discharge care for patients transitioning from hospital to home or other care settings. With increasing pressure on healthcare providers to reduce hospital readmission rates, the need for efficient, patient-centered TCM services has never been greater. HealthViewX, a cutting-edge care orchestration platform, is at the forefront of revolutionizing TCM by streamlining processes, enhancing communication, and ultimately reducing avoidable readmissions. This blog explores how HealthViewX is transforming TCM for US providers, backed by market data and insights on its impact on patient outcomes.

The Growing Importance of Transitional Care Management

The Centers for Medicare & Medicaid Services (CMS) introduced reimbursement for TCM services in 2013 to incentivize providers to offer comprehensive post-discharge care. These services, typically provided during the first 30 days following discharge, focus on preventing complications and ensuring patients adhere to their care plans. Effective TCM programs can significantly reduce the risk of readmissions, which cost the US healthcare system billions of dollars annually.

According to a study published by the National Institutes of Health (NIH), nearly 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, costing the system $26 billion annually. Of this amount, $17 billion is considered avoidable through better post-discharge care coordination. This underlines the urgency of implementing efficient TCM programs and leveraging digital platforms to enhance these services.

The Role of HealthViewX in TCM

HealthViewX is designed to address the unique challenges of managing care transitions by providing a digital platform that streamlines communication, automates workflows, and ensures that no patient falls through the cracks. Here are some key ways HealthViewX is revolutionizing TCM for US providers:

1. Seamless Care Coordination

A major barrier to effective TCM is the lack of communication between hospitals, primary care providers, specialists, and other care team members. HealthViewX bridges this gap by offering a centralized platform where providers can share information, track patient progress, and collaborate seamlessly. The platform enables real-time updates on patient conditions, reducing the risk of errors or omissions that can lead to readmissions.

2. Automated Task Management

HealthViewX’s automation capabilities significantly reduce the administrative burden on care teams. The platform automates key TCM tasks, such as scheduling follow-up appointments, sending medication reminders, and tracking patient compliance with discharge instructions. This not only saves time but also ensures that critical steps in the care transition process are completed on time, reducing the likelihood of patient deterioration and readmission.

3. Patient Engagement and Education

One of the key drivers of successful TCM is patient engagement. HealthViewX offers tools that engage patients through automated reminders, educational materials, and personalized care plans. By ensuring that patients understand their post-discharge care instructions and adhere to their medication regimens, HealthViewX helps reduce the risk of complications that could result in hospital readmissions.

4. Data-Driven Insights

HealthViewX provides providers with access to comprehensive data analytics that allows them to track outcomes, identify high-risk patients, and measure the effectiveness of their TCM programs. By leveraging this data, providers can make informed decisions on how to optimize care transitions, focus resources on patients most at risk of readmission, and ultimately improve care quality.

Reducing Readmissions with HealthViewX: The Impact

HealthViewX’s platform has been shown to significantly reduce hospital readmission rates for providers implementing robust TCM programs. Studies show that effective TCM can reduce readmissions by up to 25%, which has a substantial financial impact on hospitals and healthcare systems. For example, hospitals that reduce their 30-day readmission rates can avoid CMS penalties, which are imposed under the Hospital Readmissions Reduction Program (HRRP).

Market data supports the value of reducing readmissions. A report by the American Hospital Association (AHA) found that hospital readmissions cost the healthcare system $41.3 billion annually. By leveraging HealthViewX’s digital tools, providers can make significant strides in cutting these costs while improving patient outcomes.

The Financial and Operational Benefits of TCM with HealthViewX

Implementing HealthViewX’s TCM solution offers not only clinical benefits but also financial and operational advantages for healthcare providers:

1. Reduced Penalties

CMS imposes penalties on hospitals with high readmission rates. By reducing readmissions through effective TCM, HealthViewX helps hospitals avoid these financial penalties. In 2023 alone, CMS penalized 2,273 hospitals, with a cumulative penalty of $320 million. Implementing a robust TCM program powered by HealthViewX can mitigate these risks.

2. Increased Reimbursements

Providers offering TCM services are eligible for Medicare reimbursements under specific CPT codes (99495 and 99496), which cover both non-face-to-face and face-to-face patient interactions post-discharge. By using HealthViewX to automate and document these interactions, providers can ensure they capture all billable services and maximize revenue.

3. Enhanced Care Team Efficiency

By automating administrative tasks and improving communication, HealthViewX allows care teams to operate more efficiently. This not only reduces the risk of burnout but also ensures that more time is spent on direct patient care rather than paperwork. In a survey conducted by the Medical Group Management Association (MGMA), 78% of respondents cited administrative burden as a significant challenge in managing transitions of care. HealthViewX alleviates this pressure through intelligent automation.

Conclusion

HealthViewX is transforming the landscape of Transitional Care Management for US providers. By streamlining communication, automating workflows, and engaging patients, the platform significantly reduces readmission rates, enhances patient outcomes, and offers financial benefits for healthcare providers. In a healthcare environment increasingly focused on value-based care, the adoption of digital platforms like HealthViewX is essential for success.

As hospital readmissions continue to be a costly problem for the US healthcare system, HealthViewX’s innovative approach to TCM provides a clear path forward for improving post-discharge care and reducing avoidable readmissions. Through seamless care coordination, automation, and data-driven insights, HealthViewX empowers providers to deliver better care while optimizing financial and operational performance.

Medicare CCM Program: How HealthViewX Makes a Difference

Chronic illnesses, such as diabetes, hypertension, and heart disease, pose a significant healthcare challenge. Managing these conditions effectively requires ongoing care and coordination. To address this, the Medicare Chronic Care Management (CCM) program was introduced to provide comprehensive care for patients with multiple chronic diseases. It is a valuable initiative that aims to provide better care, reduce healthcare costs, and enhance the quality of life for individuals with complex health needs.

The CCM program not only provides better care for patients with chronic conditions but also offers healthcare providers an opportunity to improve their revenue streams. Under this program, healthcare providers are reimbursed for offering non-face-to-face care coordination services to eligible Medicare beneficiaries.

However, delivering CCM services profitably can be challenging without the right tools and technologies. In this article, we explore how HealthViewX, a care orchestration technology platform, empowers clinicians to deliver CCM services profitably, all while enhancing patient care.

The Profitability Challenge

While the Medicare CCM program presents a unique revenue opportunity for clinicians, it also comes with its challenges. To deliver CCM services profitably, clinicians must navigate a range of complexities, including administrative tasks, data security compliance, managing care team and patient engagement. This can be daunting, time-consuming, and costly without the right support.

How HealthViewX Empowers Clinicians

HealthViewX is a transformative healthcare technology platform that offers a suite of features designed to streamline and optimize the delivery of CCM services. The platform capabilities empower healthcare providers to deliver more effective and personalized care to patients with chronic conditions, ultimately leading to better health outcomes. Here’s how HealthViewX helps clinicians deliver the CCM service profitably:

Automated Administrative Tasks: HealthViewX platform empowers clinicians to identify eligible patients, enhance patient enrollment process, create personalized care plans, capture and document accurate time spent with patients by tracking calls & emails. This automation reduces the time and effort required for administrative tasks, allowing clinicians to focus on patient care.

Care Coordination at Its Best: HealthViewX excels in care coordination, which is fundamental to the success of Medicare CCM. The platform streamlines communication among care team members and this synergy ensures that all parties involved in a patient’s care are on the same page, leading to more effective treatment plans and improved patient outcomes. Engaged patients are more likely to adhere to treatment plans, make healthier lifestyle choices, and actively participate in their own care.

Care Plan Customization: HealthViewX has got over 86 pre-defined care plan templates based on various conditions that helps clinicians to create personalized care plans tailored to each patient’s unique needs. This not only improves patient outcomes but also increases patient satisfaction, leading to better retention and profitability.

Targeting High-Risk Patients: Not all patients with chronic conditions have the same level of risk. HealthViewX employs risk stratification algorithms to identify high-risk individuals who require more intensive care management. By focusing resources on those who need it most, healthcare providers can allocate their resources and efforts effectively for improved outcomes.

Billing and Documentation: Billing and documentation are essential aspects of Medicare CCM. The platform simplifies billing and documentation processes, ensuring that clinicians efficiently document patient interactions and maximize their reimbursements for CCM services. It helps clinicians avoid revenue loss due to incomplete or inaccurate billing. It also lets providers generate billing reports based on CMS guidelines for guaranteed reimbursement.

Secure Patient Data: HealthViewX prioritizes the security and privacy of patient data, ensuring that sensitive health information remains protected. Compliance with data security standards is critical to maintaining trust with patients and regulatory authorities.

Analytics and Reporting: HealthViewX offers robust data analytics tools that enable healthcare providers to track the performance of their CCM services and patient outcomes over time. By analyzing trends and patterns in patient data, providers can make informed decisions and adjust care plans as needed. This data-driven approach promotes evidence-based care, continuous improvement and increased profitably.

Cost Savings: By automating administrative tasks, reducing non-compliance risks, and improving patient engagement, HealthViewX ultimately saves clinicians time and resources, contributing to increased profitability.

Conclusion

Medicare’s Chronic Care Management program was introduced to help manage the health and well-being of beneficiaries with multiple chronic conditions. The Medicare CCM program is a unique opportunity for clinicians to provide better care for patients with chronic conditions and boost their practice’s revenue. By automating administrative tasks, ensuring regulatory compliance, enhancing patient engagement, and optimizing billing, HealthViewX emerges as a game-changing solution that empowers clinicians to achieve profitable outcomes while delivering high-quality care. As the healthcare landscape continues to evolve, technology solutions like HealthViewX will be instrumental in transforming healthcare practices, and also in making the CCM program more accessible and profitable for clinicians.

Earn from Medicare’s Chronic Care Management Program! CCM made simple!

Chronic Care Management Services are delivered to Medicare beneficiaries with two or more chronic conditions with the goal of improving health and quality of care for high-need patients. As the population ages, FQHCs, RHCs, ACOs, hospitals, individual practitioners, etc. face the daunting challenge of improving the quality of care for chronically ill patients while containing costs.

The Centers for Medicare and Medicaid Services (CMS) say about 93% of total Medicare spending is on beneficiaries with multiple chronic conditions. Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions is more likely to present in emergency rooms, and be admitted than others.

Despite the need for proactive care for chronic care management patients, a lot of the providers are still underutilizing this benefit. There are several reasons why providers like FQHCs, RHCs, ACOs, hospitals, individual practitioners, etc. have chosen to leave it on the table.

Complicated Process:

There are several rules physicians and practices have to follow to qualify for CCM reimbursement. CMS has set rules right from enrolling Medicare patients up to the necessary documents that have to be furnished for CCM reimbursement. Other mandatory requirements include providers offering CCM service, having access to patients’ health records, providing 24/7 access to care, providing care plans, and patients being able to reach providers to meet urgent care needs.

Time Consuming and involves additional costs:

Many providers feel offering CCM service is a time-consuming effort, and requires additional staffing. They find it difficult to document each of these and also provide quality care for their patients. Providers feel there is an increased administrative burden to managing and tracking CCM services, and it also involves additional costs.

Patients Consent:

Providers must identify Medicare eligible patients, explain CCM services, and get consent to enroll the patient and start the service. Providers must explain the required information in detail so that the patient can either accept or decline the service.

Wait and See Approach:

Providers want to first see if the approach is effective before opting for it. Many providers and physicians wait to see if other providers who opt to provide the service have success with reimbursement before committing to participation in the program.

HealthViewX makes the Chronic Care Management process easier with the below features and makes reimbursement simple:

Automated Documentation for CMS Auditing

HealthViewX automates and streamlines the end-to-end CCM process. Integrates with softphones to accurately record the time spent on each call. It easily helps generate reports as per CMS requirements.

Comprehensive Care Plan

Structured care plans are essential to help organize the coordination of actions for proper patient progression and self-management. The solution helps create condition-specific, personalized, and comprehensive care plans for each patient, including tasks and goals for both the patient and care coordinator track for better care coordination. Simplifies and streamlines workflow to guide tele-nurses in creating care plans.

HIPAA Compliant

HealthViewX CCM follows HIPAA compliance requirements and guidelines. The solution lets you define the access, has user-specific access conditions, and provide secure access to patient records.

Analytics and Dashboard

Gives detailed actionable insights for better care coordination. Data can be visually represented, and users can gather detailed information by clicking the desired data. The dashboard also displays the follow-up reminders that can be set up by the user against each patient.

Take this simple step to improve health outcomes and reduce costs for patients with multiple chronic care conditions.

Schedule a demo and talk to HealthViewX solution experts today to discuss the CCM solution. Or simply outsource your CCM services. HealthViewX also provides end-to-end CCM services through our network of seasoned RNs and CMAs that enable you to increase your monthly reimbursements without incurring any additional cost of hiring additional staff or investing in technology solutions.

Earn from Medicare’s Chronic Care Management Program! CCM made simple!

Chronic Care Management Services are delivered to Medicare beneficiaries with two or more chronic conditions with a goal of improving health and quality of care for high-need patients. As population ages, FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. face the daunting challenge of improving quality of care for chronically ill patients while containing costs.

The Centers for Medicare and Medicaid Services (CMS) says about 93% of total Medicare spending is on beneficiaries with multiple chronic conditions. Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions are more likely to present in emergency rooms, and be admitted than others.

In spite of the need for proactive care for Chronic Care Management Patients, a lot of the providers are still underutilizing this benefit. There are several reasons why providers like FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. have chosen to leave it on the table.

Complicated Process:

There are several rules physicians and practices have to follow in order to qualify for CCM reimbursement. CMS has set rules right from enrolling Medicare patients up to the necessary documents that have to be furnished for CCM reimbursement. Other mandatory requirements include providers offering CCM service, should have access to patient’s health records, provide 24/7 access to care, provide care plans, and patients be able to reach providers to meet urgent care needs.

Time Consuming and involves additional costs:

Patients Consent:

Providers must identify Medicare eligible patients, explain CCM services and get consent to enroll the patient and start the service. Providers must explain the required information in detail where the patient can either accept or decline the service.

Wait and See Approach:

Providers want to first see if the approach is effective before deciding to opt for it. Many providers and physicians wait to see if other providers who opted to provide the service have success with reimbursement before committing to participation in the program.

HealthViewX makes Chronic Care Management process easier with the below features and makes reimbursement simple:

Automated Documentation for CMS Auditing

Comprehensive Care Plan

Structured care plans are essential to help organize coordination of actions for proper patient progression and self-management. The solution helps create condition-specific, personalized and comprehensive care plans for each patient including tasks and goals for both the patient and care coordinator track for better care coordination. Simplifies and streamlines workflow to guide tele-nurses in creating care plans.

HIPAA Compliant

HealthViewX CCM follows HIPAA compliance requirements and guidelines. The solution lets you define the access, have user-specific access conditions, and provides secure access to patient records.

Analytics and Dashboard

Gives detailed actionable insights for better care coordination. Data can be visually represented and users can gather detailed information by clicking the desired data. The dashboard also displays the follow-up reminders that can be set-up by the user against each patient.

Take this simple step to improve health outcomes and reduce costs for patients with multiple chronic care conditions.

Schedule a demo and talk to HealthViewX Solution experts today to discuss the CCM solution. Or simply outsource your CCM services. HealthViewX also provides end-to-end CCM services through our network of seasoned RNs and CMAs that enable you to increase your monthly reimbursements without incurring any additional cost of hiring additional staff or investing in technology solutions.

What’s New with CCM? Medicare Reimbursement 2020 Code Changes Explained!

First, let’s have a quick look at what were the codes in 2019.

Beginning January 1, 2019, the CCM codes were as below

CPT 99490 (Non-complex)

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.

CPT 99491

Chronic care management services, provided personally by a physician or nurse practitioner for at least 30 minutes, per calendar month to high-risk patients. Codes 99490 and 99491 cannot be billed in the same month for the same patient so practices will need to decide if this new code is a good use of their doctors’ time and which patients would benefit from it.

CPT 99487 (Complex)

Complex chronic care management services, with at least 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

CPT 99489 (Add-on for CPT 99487)

Each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (List separately in addition to code for primary procedure).

Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately. Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes in addition to the first 60 minutes of complex CCM services during a calendar month.

The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both. Do not report 99491 in the same calendar month as 99487, 99489, 99490.

What’s New?

On Nov 15, 2019, Centers for Medicare and Medicaid Services (CMS) finalized the CY 2020 Medicare Fee Schedule (MFS). It has revised the current chronic care management reimbursement program and has created a new care management reimbursement program.

Here’s a quick look at 2020 Medicare Reimbursement Codes for Chronic Care Management:

99487, 99489*, 99490, G2058*, 99491

CMS has created an add-on code, HCPCS Code G2058 for non-complex CCM effective Jan 01, 2020.

G2058 Specifications:

A medical practitioner can bill CPT 99490 for the first 20 minutes of clinical staff time spent performing CCM activities (educating the patient or caregiver about the patient’s condition, care plan, and prognosis, etc.) in a given calendar month and can charge HCPCS code G2058 for the second and third 20-minute additions (additional staff time respectively). Use G2058 in conjunction with 99490. Do not report 99490, G2058 in the same calendar month as 99487, 99489, 99491. These CPT codes are tailored toward primary care physicians but can be billed by any physician or by any skilled healthcare professional and get the reimbursement by fulfilling the code requirements.

Payment or reimbursement for the CPT code 99490 is $42.23 while the add-on code G2058 (up to two) pays $37.89. Therefore, total reimbursement for an hour or more of non-complex CCM services is $118.01.

** Add-on codes are bundled and cannot be billed separately from their base code.

CCM Patient Eligibility

Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services.

How does the scope for CCM look like in 2020?

Qualified healthcare professionals have been billing Medicare for providing CCM services like maintaining care plans, handling care transitions between providers to Medicare patients with two or more chronic conditions. Even today CCM continues to be underused.

The epidemic of chronic disease continues to grow and has reached global epidemic proportions. This condition is exerting considerable demand for health systems to adopt an IT solution to provide better care for their chronic patients. This increased demand has become a major concern today. Adapting new technology or operating models is vital for the health systems to provide care differently, more efficiently, and with better patient outcomes.

HealthViewX CCM platform helps individual physicians, practices, billing companies, etc. to provide CCM services seamlessly to their enrolled Medicare patients. The simplified and automated process makes it easy to meet the criteria for CMS billing and reimbursement.

Power your entire system – simplify your workflow, create patient-specific care plans, automate documentation, generate detailed reports, and improve overall efficiency. Hosted in cloud servers, HealthViewX CCM solution is extremely scalable to meet requirements of any operative size and our pricing model keeps overhead cost minimal and manageable.

Schedule a demo and talk to our solution experts today!

Ref: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

https://hcpcs.codes/g-codes/G2058/