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Exploring chronic care management adoption for primary care physicians

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Chronic health conditions are extremely prevalent in the United States, accounting for more than $4 trillion in annual healthcare costs, according to the Centers for Disease Control and Prevention. What's more, the CDC estimates that six out of 10 Americans live with a chronic health condition. Four out of every 10 have at least two or more. However, many patients with chronic conditions struggle to get the care that they need which can negatively affect their overall health.

For practices that treat patients who have two or more chronic health conditions, implementing a Chronic Care Management program can be extremely beneficial.

What is Chronic Care Management?

The Centers of Medicare and Medicaid Services (CMS) defines chronic care management as any activities performed by a physician or health care provider outside of a regular office visit in order to provide better patient health and care. These activities can include patient education, medication management and support, coordination of care transitions, and care planning.

The Increased Need for Chronic Care Management

At the same time, as the population in the US ages, more patients will need care for chronic conditions. Those over the age of 65, a group that is increasing in numbers as Baby Boomers enter the age of retirement and Medicare eligibility, are more prone to conditions such as arthritis, hypertension, diabetes, and other chronic conditions that will require management by primary care physicians.

A recent survey conducted by Quest Diagnostics explored the adoption of chronic care management. The survey, involving 801 primary care physicians and patients over 65 with multiple chronic conditions, found that primary care physicians feel “overwhelmed and overworked.” These physicians want to spend more time with the patients who need them most but feel their lack of time impedes the quality of that care.

Specifically, the survey found that “almost nine in ten PCPs (86%) say they have felt unable to address the needs of their chronic care patients adequately, with almost three in ten (28%) saying this happens a lot. For most physicians—85 percent—lack of time is the key culprit.”

Although most (95%) of the physicians participating in the survey said they are in primary care because of a desire to care for the “whole patient,” two-thirds (66%) of them say they “don’t have time to address social and behavioral issues, such as loneliness or financial concerns, that could affect the health of their patients,” possibly contributing to or exacerbating chronic conditions among those patients. Only 9% of the physicians participating in the survey are “very satisfied that their patients are getting all the attention they need to care for all medical issues.

Patients with chronic conditions also typically require continued medication and, in fact, account for 83.1 percent of all prescriptions in the United States. The surveyed physicians indicated they felt the need to follow up with these patients to ensure they understand their instructions fully, with 88% saying they are “concerned their Medicare patients with multiple chronic conditions are not taking their medications as prescribed.”

An additional challenge for primary care physicians treating patients with chronic health conditions is the Medicare reimbursement schedule. Most of the physicians surveyed stated they need to see these patients multiple times throughout the year, to properly manage their conditions; however, under Medicare, patients are eligible for an introductory preventive visit within 12 months of qualifying for Medicare and an Annual Wellness Exam every year thereafter.

Adding CCM Services to Your Practice

Chronic care management can help you provide better quality care for patients with chronic health conditions and provide a way to increase revenue for your practice. Medicare beneficiaries who qualify for CCM services will gain a team of dedicated health care professionals who can provide support to help them plan for and better manage their health.

Patients enrolled in a CCM program will receive a comprehensive care plan to clearly define health management goals, including physical, mental, and brain health. You can also provide patients with a list of educational and community resources. All members of the care team should encourage patients to take an active role in their treatment plan. Getting this extra support can motivate patients to become more aware of taking medications, managing their fall risk, and other self-management tasks. Frequent check-ins can also encourage patients to stay on track with their health plan and make them feel more connected to their care team.

Eligibility for CCM

Patients who are eligible for CCM must have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient. The diagnosed chronic conditions for CCM are up to the healthcare provider's discretion. Care management services are not limited to specific conditions as long as the other requirements for the type of care management services are met.

Examples of common chronic conditions include:

  • Alzheimer's disease and related dementia
  • Cancer
  • Diabetes
  • Hypertension
  • COPD
  • Atrial Fibrillation
  • Chronic Kidney Disease

The CMS Chronic Condition Data Warehouse is a good source for a more extensive list of qualifying conditions.

Before enrolling a patient in a CCM plan, the patient must have seen their physician within the last 12 months. The visit must fall under the guidelines for an evaluation and management (E/M) visit, annual check up, or an initial physical exam. Chronic care management services do not have to be discussed during this visit in order to begin care. Care management services can begin immediately if the patient has seen their doctor within the last year and consent for care services to be performed. Getting written or verbal consent helps ensure patients are engaged and aware of the costs associated with the CCM services you will provide.

What are the billing requirements?

In order to be reimbursed by CMS for the services you are providing, you will need to create and monitor a comprehensive care plan for each patient. The care plan should include a full list of health issues with a focus on managing chronic conditions.

Only one physician or other qualified healthcare professional who manages the care for a Medicare beneficiary can bill for providing CCM services to that patient in a given calendar month. While services may be provided by a member of the care team, only these physicians and Non-Physician Practitioners may bill for CCM services:

  • Physician
  • Certified Nurse Midwives (CNMs)
  • Clinical Nurse Specialists (CNSs)
  • Nurse Practitioners (NPs)
  • Physician Assistants (PAs)

When billing, you will need to calculate the time spent on CCM for each patient monthly.

The four most common CPT codes used to bill CCM services are:

  • CPT 99490 – CCM, first 20 minutes clinical staff time (one time per month)
  • CPT 99439 – Each additional 20 minutes of clinical staff time
  • CPT 99491 – CCM, first 30 minutes physician time (one time per month)
  • CPT 99437 – Each additional 30 minutes of physician time

For patients with more complex care plans, a fifth CPT code may be used. CPT code 99487 shares common service guidelines with CCM, but has different requirements for service time provided and the complexity of the medical decision making involved.

CPT code 99487 requires:

  • At least 60 minutes of clinic staff time, and
  • Moderate to high complexity medical decision making

Here is a breakdown of the payment structure your practice can use for non-complex care:

  • For the first 30 minutes of physician time: bill 99491 ($86.17)
  • For the first 20 minutes of clinical staff time: bill 99490 ($64.02)
  • The total for this patient is equal to $150.19

If you complete 100 patient encounters each month, your practice has the opportunity to add more than $15,000 in revenue.

Remember, CCM services must meet all coverage criteria and be reasonable and necessary in order to be reimbursed by Medicare.