Improving Chronic Care Management – and getting paid for it

CMS has recently released a few new CPT codes that allow organizations to bill for transition of care management and chronic care management, which can lead to significant returns. In a recent conversation, Nordic Director of Optimization Solutions Rick Shepardson explains what you need to do to take advantage of these new codes.

CMS has released new CPT codes that offer organizations the opportunity to bill for some value-based care services. How can organizations use these codes?

Rick Shepardson

From a reimbursement perspective for Medicare, there are a few codes that have been released in the last couple of years. In 2013, CMS released transition of care management (TCM) codes, 99495 and 99496, to allow organizations to bill for post-acute care follow-up to help patients transition to outpatient settings. Then, in 2015, just this year, there was a new code for chronic care management (CCM), 99490.

Transitional care is really meant for patients who have recently left an inpatient setting and are going to receive care within the first 30 days after their discharge. 99495 is used for moderate complexity patients within 14 days of discharge, and 99496 can be used for high complexity patients seen within seven days of discharge. Chronic care management is focused on ongoing care of patients with two or more chronic diseases. Organizations need to provide at least 20 minutes of care within a 30-day period to be able to bill for these services.

Providing and billing for CCM care is a greater departure from typical fee-for-service models than TCM, but if you have the right infrastructure set up operationally, and you have technology that supports those operations, it can be a pretty big win for organizations and patients.

What kind of wins are we talking about?

Really, we’re talking about improving preventative health measures and providing better care for populations while allowing organizations to get paid in a more prototypical fee-for-service model. The incentive is for patients to receive more consistent care, improve their health, and reduce their overall cost of care. There are also financial opportunities for organizations that provide care.

There is a pretty significant ROI opportunity for organizations, isn’t there?

There is an opportunity for significant ROI with CCM. Organizations can be reimbursed $42 per month per patient by Medicare, and there’s an $8 copay. The combination of those two, if you have 2500 Medicare patients or Medicare advantage patients that are within your program, you’re expected to get potentially a million dollars a year in revenue. I’d say that’s pretty significant.

That revenue must come at a cost. How does somebody get started in optimizing their chronic care management offering?

It all starts out with developing an organizational staffing model. It’s important to define the role of staff who will be reaching out to patients and providing ongoing care. For CCM, the billable time is all non-face-to-face time and there are pretty flexible requirements regarding the type of staff that can be involved. It is a requirement that patients have 24/7 access, and that they can get all of their questions answered; everything from, “Hey, I have a question about my insurance form,” or “I have a question about my medications that I’m taking,” or “I’m really looking for a community program that will allow me to go swimming because that is good for my long-term preventative care.” While establishing staffing models, organizations have to decide if they want to provide services through a centralized or decentralized structure and whether or not to contract third parties to help provide these services.

For TCM, organizations need to reach out to discharged patients within two days of service and check in on their progress and discharge instructions and medications. The patients then need to be seen in a focused office visit within seven or 14 days of discharge. Organizations face similar staffing model discussions regarding role definition, and centralization though the considerations are different than CCM.

Once the staffing model is in place, organizations need to update EHR workflows to help support documentation and charging needs. The EHR needs to allow for targeting patients for care, efficient documentation of the amount of time spent providing care, facilitate viewing and documenting against a plan of care, facilitate coordination between all numbers on the care team, and to be able to track that time and generate claims to Medicare.

You’ve talked a little bit about how this relates to a population health program. Is this a separate subproject within a larger population health initiative, or is this just on its own? How would you look at this as an executive looking at running something like this? Where does this fit? How does this fit?

Both TCM and CCM fit into a population health paradigm but organizations don’t necessarily have to move all in and focus on a full scale population health offering. Organizations should really consider implementing these programs, developing competency in value-based care and then consider further population health measures. While population health is popular in the industry, from an executive perspective, it is important to consider potential implications including the potential impact on admissions, emergency room utilization, and PCP utilization. I think everyone wants to help keep patients healthier but it is also important to consider the impact this will have on the bottom line financially and ensure the organization is ready for it.

You talked a lot earlier about setting up the care management responsibilities. If somebody wanted to look at best practices or where to get started with that, where would you point somebody?

CCM is a brand new code for 2015. The excitement in the industry had led to detailed analysis of the requirements, and EHRs have established best practice workflows for using their current toolsets to meet these new care needs. CCM workflows can be structured similarly to TCM, and looking at those organizations who have already developed good staffing and documentation models, they are a good starting point for CCM. It’s going to help you understand which staff maybe is most appropriate to do this, how you can best reach out to your patients and make sure that they’re getting the care they need. Then, really be able to use some of the documentation tools that have been created.

We’ve talked a lot about some of the benefits of implementing this new code, billing against this new code, a little bit about the team that might be required, and some of the change that would be required within the EHR. People are going to be just wondering generally, what kind of initiative is this? Is this a huge thing? Is it a small thing?

We have done a lot of work analyzing the regulations, understanding operational needs, and the EHR requirements, and we think CCM is something that we can help organizations roll out in 2-3 months. It is important to start with some initial staffing decisions and then building out the EHR to keep things as efficient as possible. If organizations are being reimbursed for 20 minutes of care, but it takes another 20 minutes to document that care, that is a lot of overhead. Additionally, if you try to integrate third party systems, and users need to jump in and out of screens all day, that leads to additional inefficiency. It is important to really think this solution all the way through and use as much system automation as possible.


Topics: billing, transition of care management, chronic care management (CCM), CPT, EHR optimization