The expansion of Medicare’s Chronic Care Management (CCM) program in 2017 has resulted in an exciting time of change and growth for the healthcare industry and made it easier than ever to implement CCM in support of patients and the practice. Whether your organization is evaluating your CCM options for the first time or looking to expand your care coordination efforts, there are lessons learned since the program’s inception and proven strategies that can help you make the most of the CCM opportunity.
When the Centers for Medicare and Medicaid Services (CMS) implemented the Chronic Care Management (CCM) program with CPT Code 99490 in January 2015, it felt in some ways like we had a new branch or specialty of healthcare that doctors could be paid for.
Suddenly, physicians were being reimbursed for providing at least 20 minutes of non-face-to-face care coordination services to eligible Medicare beneficiaries with two or more chronic conditions. It was certainly different than their traditional fee-for-service approach to in-office care. But for some physicians, it was a way to finally be paid for the extra care coordination they were already doing for patients and/or a means to offer the type of individualized, between-visit care they had always wanted to provide.
At first there was some skepticism about the program and even confusion about what CCM really was. What was Medicare going to do with the program and how were patients going to relate to it? How would patients react to the cost sharing aspect? How would practices effectively implement CCM? And if physicians did what they were being asked to do, would CMS suddenly change the rules on them?
Anyone involved in healthcare knows these are all valid questions to ask. After spending over two decades in the healthcare space, I’ve personally witnessed massive changes with CMS. I’ve seen the impact a shift in administrations can bring and witnessed the stops and starts of programs. As many of you can relate, I’ve had the opportunity to see where we advanced and where we didn’t, where things succeeded and where they failed, and where we’re going vs. where we should be going.
Since the start of the CCM program, I believe a lot of the initial skepticism has turned into enthusiasm, thanks in large part to the following:
- Positive testimonials from patients, physicians, and care coordinators that have made others anxious to implement CCM services
- Research that has demonstrated CCM’s ability to help the industry achieve the “Triple Aim” of better care, lower costs, and improved health
- Changes in 2017 that demonstrate the program’s growing value and CMS’ commitment to it
- Growing awareness that providing CCM services can set practices up for success with value-based initiatives like MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and CPC+ (Comprehensive Primary Care Plus).
Now, with so many in the industry looking to implement CCM or expand their CCM program, I wanted to share some tips for maintaining optimism in moving forward, as well as strategies for achieving maximum results from your program.
Determine the Complexity of Care Patients Need
The CCM program has grown to include the following codes for reimbursement:
- CPT 99490 - For at least 20 minutes of non-face-to-face care coordination services; reimburses a national average of $43 per patient, per month; also known as non-complex CCM
- CPT 99487 - For complex CCM cases that require more care coordination time and more complex medical decision-making; reimburses approximately $94 per patient, per month for 60 minutes of non-face-to-face care coordination services
- CPT 99489 - For complex CCM cases that require more care coordination time and more complex medical decision-making; reimburses approximately $47 for each additional 30 minutes, per patient, per month (only billable with 99487)
Identifying which patients truly require more complex medical decision-making and extra time for care coordination will be key in determining your reimbursements.
Complexity of care may also play a greater role in the future with MACRA. On June 20, CMS announced its Proposed Rule for Quality Payment Program Year 2. Included is a proposal to apply an adjustment of up to 3 bonus points by adding the average Hierarchical Conditions Category (HCC) risk score to the final score. This proposed addition means eligible clinicians could be awarded between 1 to 3 bonus points based on the medical complexity of the patients they see.
Choose Your Implementation Approach
You can implement a CCM program on your own or choose to leverage a care coordination services company to provide CCM services to your patients.
For most practices, there are significant challenges to implementing CCM on their own. It requires too much oversight, changes in workflow, changes in technology, additional human resources, and strains on time and money.
Luckily, CMS made it possible for practices to save time, money, and effort by turning to a third party to implement CCM on their behalf. With care coordination services provided to their patients by clinical staff that acts as an extension of the practice, following the preferences and protocols of the practice, physicians and practice staff can continue to serve at their highest and best use. They can focus on caring for patients, building the practice, and boosting the bottom line, while efforts associated with their CCM program work to improve patient health and generate recurring monthly revenue for the practice.
Expect Changes in Workflows
No matter how you implement your CCM program, you will have to accept some level of workflow transformation.
If you’re doing CCM on your own, you will need to direct a great deal of clinical workflow transformation. If you’re doing it with a third party, you won’t have that level of responsibility on your shoulders, but there will still be some steps in your workflow that will be different now.
It is impossible to think that CCM can be some kind of out of sight, out of mind program for the provider or practice staff. If you try to build one that way, we can tell you from experience that it will not work. We have spoken with many providers who thought they could do this on their own and without much effort, who either failed or failed magnificently. So when you think about CCM as a service or program, recognize that you will need to transform some of your workflows and set expectations to create a framework for success.
Don’t Forget What’s At Stake
This is not a one client only transaction. There are multiple stakeholders involved in a CCM program, including:
- The physician who has to understand it and articulate it.
- Individuals who will help implement it (such as care coordinators from a third party and practice staff).
- The patient who has a level of expectations that need to be set and met each and every month.
- Any family members or caregivers the patient wants included.
- The payer (Medicare) who expects CCM delivery to meet the requirements and move the needle on cost/quality.
- The additional providers who take care of the patient’s needs.
When it comes to additional providers, note that a patient age 65 or older with two or more chronic diseases sees an average of 6.1 providers. With a CCM program, that means there's one quarterback who’s huddling with five other players to call the shots for the patient. There may also be a caregiver or family members on the sidelines with questions, concerns, and ideas, as well as staff members who are trying to respond to patients about what to expect clinically or what to expect financially. Are you prepared to manage all that or do you want support in doing so?
When a patient is receiving properly coordinated CCM, the electronic care plan generated on their behalf is different from the ones typically in use. It’s also a critical element when delivering non-face-to-face care coordination services in a world where you’re used to fee-for-service.
With traditional fee-for-service, the patient arrives for their appointment and is seen in the exam room. You have a conversation, answer questions, and take notes. The patient gets their paperwork, schedules their next appointment, pays, and goes home. It is a very straightforward transaction. The patient expects, and is conditioned to, coming to an office to receive care and paying for that care. But CCM is different.
It may help to think about it this way: A non-face-to-face code is like a virtual program for which you still have to be able to articulate what it is that you are providing virtually (outside the point of care) and what the patient is receiving virtually. It’s very easy to order something from Amazon and receive it. You have record of a completed transaction in that there is some form of physical evidence that an act of commerce took place. You made an effort (placed an order) and received something in exchange.
But in terms of a CCM program, what does a provider deliver and what does a patient get? If you’re not able to articulate that, and provide evidence to the fact that you’re performing work month over month on behalf of the patient, as well as in coordination with the patient, caregiver, and other providers, you won’t be successful. Going back to my Amazon analogy, the patient will quickly say, I keep ordering something, but it never comes in the mail, so I'm going to stop ordering it.
This is one of the reasons why the cornerstone of the CCM program is an electronic care plan. Not only does having one fulfill a compliance requirement of the program, but it also acts as the tangible evidence of a virtual program. It’s the primary way that you can inform not only what the baseline understanding is among the average of six providers, but also what the delta is.
The electronic care plan has to be dynamic and able to be reinforced at the points of care. It provides road signs along the healthcare journey for the patient to follow, as well as for providers to track the patient and their progress.
Think Beyond the Requirements
If you’re looking at just the requirements of the code, that won’t create a successful program. While you have to abide by the rules Medicare outlines in the regulations for CPT 99490 and other CCM codes, we can tell you this: If you do what is only required by the code, your patient won’t get the full benefit of CCM. Using the Amazon analogy: The patient has an expectation to receive value from these services. In the absence of value, they won’t be ordering from you again.
Recognize the Connections
One final tip I’d like to share is to recognize the connections between the programs CMS initiates.
The micro changes CMS was making with the introduction of CPT 99490 were part of a macro event, the implementation of MACRA. They were preparing physicians for the transition into value-based care. And they were introducing changes to the way physicians were paid, knowing that even more changes were to come.
When you make those kinds of connections, it’s easier to see how succeeding with CCM can help you succeed with MACRA and future value-based initiatives.