Stacey Richter, host of the popular podcast Relentless Health Value, recently referred to the first year of experience working with CPT Code 99490 as a four-stage process for providers: Disbelief, Shangri-La, Anger, and then Dawning Reality. While this critical time period certainly saw its share of ups and downs, what we learned along the way has been a real eye-opener, especially for those who embraced or are about to embrace the final stage.
The Disbelief stage began with the introduction of CPT Code 99490, which created both confusion and skepticism among some providers. Here was a code that focused on expanding care for Medicare patients with two or more chronic conditions, but through non face-to-face coordination of those services. Providing Chronic Care Management (CCM) through phone calls, transcribing medical records, appointment setting, and getting authorizations or referrals, rather than inside the office or even in front of patients was a foreign concept for many.
By the second quarter, many providers had found time to research the code and further recognize the potential benefits for both patients and the practice. Most of the early adopters during this Shangri-La stage were individuals who felt they were already coordinating care for patients between office visits and could now get paid for that work. Others were those driven by the revenue incentive of the code to add this type of service. Generally, there was consensus among them that electronically documenting this type of care was the missing component to getting paid while improving patient outcomes.
Enter the third stage: Anger. By the third quarter of 2015, many providers were angry and frustrated. The issue wasn’t that they were mistaken in seeing the value of the service or having a desire to implement it. It had to do with expectations and the reality of daily operations.
As anyone in a busy doctor’s office knows, just getting through the list of patients scheduled for the day is trying enough. That doesn’t count any of the multitude of other responsibilities doctors, nurses and support staff have outside of the day’s scheduled appointments.
Now add the implementation of CCM to the mix. For many providers, just the act of getting medical records from other healthcare facilities was a big enough challenge. Without those records, the providers couldn’t form a fully comprehensive care plan that met the requirements of the code.
Staffing realities sunk in as CCM billing requires at least 20 minutes of care coordination to bill for a patient and access to services has to be available 24/7. Beyond that, there were challenges communicating and exchanging data across different electronic platforms, understanding when you could and couldn’t bill for services, and more.
The Center for Medicare and Medicaid Services (CMS) “put pretty strong requirements around a code that honestly is very time consuming,” said James Grant, a member of the Florida House of Representatives and a founding member of CareSync. The amount of work it took led some providers to conclude the revenue gained from the code wouldn’t be high enough to satisfy the ROI. But the value missed was in recognizing that CMS “allowed the provider to outsource the code using the general supervision guidelines,” said Grant.
A New Dawn in Care
This led to the Dawning Reality stage toward the end of 2015. If providers outsourced CCM, they could enroll their eligible Medicare patients, allow a qualified third party to administer the service, give patients access to the individualized attention they need, and at least be guaranteed to profit at some percentage.
What Is Key for Today
Especially as Medicare continues to shift away from fee-for-service (FFS) care to a more value based care model, it becomes increasingly important to find a full-service care coordination company. Look for:
One with the thought leadership to get the most value from Medicare’s current initiatives and the resources and foresight to support Medicare’s future initiatives
A proven track record with the code, preferably with experience since day one, to ensure compliance and a supportive knowledge base
An implementation model that allows you to get started quickly, with minimal effort
The staffing scale to honor its commitments (a well-established firm with Healthcare Assistants available 24/7/365)
A fixed cost per month per patient (this way, if care coordinators take 20 minutes or four hours with a patient, your cost stays the same)
What Is Key for Tomorrow
As influential as the introduction of code 99490 has been for care coordination, it was just the first building block in the creation of a new reimbursement model that moves away from payment based on the amount of care to payment based on the level of care.
If the proposed key provisions for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) are any indication, we are on the fast track toward this shift. Providers who understand care coordination, embrace proactive between-visit care, engage patients to become active participants in their health, and start making the transition towardvalue based care earlier rather than later will be better-positioned to succeed.