Chronic Care Management What do you need to know to Design and Implement Successful Program
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The document provides an overview of Chronic Care Management (CCM) and Principal Care Management (PCM) programs, detailing their requirements for Medicare billing and the historical evolution of these services from 2015 to 2023. It outlines patient eligibility criteria, activities involved in CCM, and who can bill for these services. Additionally, it discusses the benefits and drawbacks of implementing and outsourcing CCM, including financial implications and impacts on patient care quality.
Chronic Care Management What do you need to know to Design and Implement Successful Program
- 1. Chronic Care Management (CCM): What Do You Need to Know to Design and Implement a Successful Program Irina Koyfman, DNP, NP-C, RN CEO of Affinity Expert www.AffinityExpert.com Irina@Affinityexpert.com
- 2. Learning Objectives Review CMS’s Chronic Care Management (CCM) and Principal Care Management (PCM) requirements 01 Examine Scope of Services required to bill Medicare for CCM/PCM services 02 Identify what is needed for successful plan 03 Summarize Evaluation plan 04
- 3. HISTORY of CCM 2015- Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with 2 or more chronic conditions. 2019 -CMS acknowledge that CCM services demonstrate increase in patient and practitioner satisfaction, as well as costs saving (CMS, 2019). 2021 -CMS made changes by adding Principal Care Management (PCM) code for a single disease and encourage providers to utilize more of the CCM services by allowing CCM to be billed in conjunction with the Transitional Care Management (TCM) (CMS, 2020).
- 4. HISTORY of CCM 2022 CMS’s dramatically increased reimbursement to providers (~50%) AND Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same time period. 2023- FQHCs able to bill multiple times for CCM services using HCPCS code G0511, reflecting the increased complexity of care.
- 5. WHAT IS Chronic Care Management
- 6. CCM is the care coordination/care management that is happening outside of the regular office visit for patients with multiple (two or more) chronic conditions.
- 7. Patients’ Eligibility Medicare patients with at least 2 chronic medical conditions that: Are expected to last at least 12 months or until the death of the patient; OR, – place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
- 8. Examples of Chronic Conditions Alzheimer’s disease and related dementia Arthritis (osteoarthritis and rheumatoid) Asthma Atrial fibrillation Autism spectrum disorders Cancer Cardiovascular Disease Chronic Obstructive Pulmonary Disease Depression Diabetes Hypertension Infectious diseases such as HIV/AIDS
- 10. Who can bill for CCM? Physicians and the following Non-Physician Practitioners (NPP): Certified Nurse Midwifes Clinical Nurse Specialists Nurse Practitioners Physician Assistants RHC and FQHC Hospitals & Critical Access Hospitals
- 11. Who can NOT bill for CCM? limited license physicians and practitioners like: Clinical psychologists Podiatrists Dentists Only 1 Provider can bill for a patient monthly
- 12. Who can provide CCM If billing practitioner doesn’t personally furnish the services, the clinical staff furnish them under direction (general supervision) of the billing practitioner on an incident to basis
- 13. Principal Care Management (PCM) PCM is provided for patients with ONE chronic condition - Specialist ( usually) A difference is that PCM has a time requirement of 30 minutes a month, verses CCM’s 20- minute requirement
- 14. Benefits of Implementing CCM Financial – 100 patients on CCM can generate about $80,000 Improved patient and provider satisfaction (CMS, 2021) • Study showed an improvement in blood pressure control (Hoehns et al., 2020) • Significant reduction in COPD hospital readmission was achieved (Press et al., 2021) • Stronger care coordination was achieved between PCP and specialists (Flieger et al., 2019) • And much, much more Improved patient’s clinical outcome
- 15. Pros and Cons of Outsourcing CCM PRO • Fast implementation • Less expensive (pay per performance) • No need to manage, just oversee • No need for platform and tech • Easily scalable Con • Less ability to manage the team • Less visibility of work • Depending on the vendor – less integrity • Providers are less engaged (enrolment and management) • Less collaboration
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