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Chronic Care Management – Decoded (FAQ)

Chronic diseases are a long-term illness that needs special care and periodic evaluation. Conditions such as diabetes, cancer, heart diseases, high blood pressure and so require continuous care and help.

Both diagnosis and treatment cost of any chronic disease is very expensive. And, if a person has multiple chronic conditions, the costs will skyrocket. That’s where Medicare comes to play, like other health insurance it pays half of the treatment and care cost.

What is Medicare?
Medicare is a health insurance program administered by the U.S. Federal government for people aged 65 or above, and for people with certain disabilities and end-stage renal disease of any age.

What is Medicare Chronic Care Management service?
Under Medicare payment, a Chronic Care Management service will be provided to patients with multiple (two or more) chronic conditions by a physician or skilled professional per calendar month.

Examples of the chronic condition include, but not limited to, the below list

- Alzheimer’s Disease and Related Dementia		 - Heart Failure
- Arthritis (Osteoarthritis and Rheumatoid)		 - Hepatitis (Chronic Viral B & C)
- Asthma						 - HIV/AIDS
- Atrial Fibrillation					 - Hyperlipidemia (High cholesterol)
- Autism Spectrum Disorders				 - Hypertension (High blood pressure)
- Cancer (Breast, Colorectal, Lung, and Prostate)	 - Ischemic Heart Disease
- Chronic Kidney Disease				 - Osteoporosis
- Chronic Obstructive Pulmonary Disease		         - Diabetes
- Depression						 - Stroke
- Schizophrenia and Other Psychotic Disorders

What is CPT 99490?
Chronic Care Management Services, takes at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:
● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
● Comprehensive care plan established, implemented, revised, or monitored

What are the new complex CCM codes?
CPT 99487 – Complex Chronic Care Management Services, with the following, required elements:
● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
● Establishment or substantial revision of a comprehensive care plan
● Moderate or high complexity medical decision making
● 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

CPT 99489 – Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

How do physicians get paid for CCM services?
Mostly primary care physicians can bill for CCM service and in some cases, specialists involved in care can also bill. But only 1 practitioner can be billed per patient per calendar month for either complex or non-complex code.

What is the best way to keep track of chronic care minutes?
Care providers generally keep track of the service time. A tracking software can be used to track every minute spent on care and documentation is done for reimbursement purpose. Based on the service offerings, time will be tracked for every interaction made with the patient on a monthly basis.

How to start Chronic Care Management to patients?
Patient with multiple chronic conditions first needs to enroll for CCM care service. Then physician or care professionals will provide care according to needs of the patient. This service will be then documented for billing.

Is there any chronic disease Self- Management Program?
Yes!. A low-cost Chronic Disease Self-Management Program (CDSMP) helps chronic patients to learn how to manage and improve their own health. An interactive session will be conducted for patients with the common disease by doctors that cover pain management, nutrition, exercise, and medication use.

Home Health Care for Chronic Disease Management

Home health model is established with an objective to deliver high-quality care at each level of healthcare delivery chain. As we all know this is offered at the patient’s residence by either licensed health care providers or caregivers.

Home Health Agencies are certified centers that provide skilled care for older Americans, people with disabilities or for people who suffer from acute and chronic conditions.

There are about 83.7 Million people in the US who are benefiting through home health agencies.
As a result of this parallel growth of both aged population and chronic diseases, the need for optimum care delivery continues to grow.

For elder care help, CMS offers to pay home health agencies for providing 60 days of care under HHA PPS.

So, how does home health agencies get patients?

On the basis of illness or injury, doctors send people who need care services to home health. Mostly Medicare patients, people with 2 or more chronic conditions who need care after discharge will be shifted to home health immediately following hospitalization.

Patient-centric care is provided to see quick progress in their health considering the needs of the patient and doctor recommendations.

How does a care coordination model work?

Once a patient is referred, a care plan is set with goals to regain patient health status. Some home health agencies have started embracing technology platforms through which automated care plans can be generated using Care Management Software.

Care plans are set with goals and rolled out to patients. Health status will be continuously monitored by skilled professionals at regular intervals and if required changes will be made looking at real-time health data.

Both patient and the providers are equally involved in the care cycle and are expected to work together and achieve health goals to ensure patient recovery.

Multiple specialists will be connected in this care loop to better collaborate, communicate and coordinate care whenever there is a necessity or emergency.

Coaching will be given with the help of patient education tablets to connect and follow the care goals for quicker recovery. Home health also organizes a community meeting where people facing the same kind of illness will share their experiences to encourage and motivate to fight against chronic illness.

Telehealth Home Service

Many US seniors enjoy living independently at their own place and need a little help from providers when they get ill. Telehealth is a gift for those to improve their health thus promoting independent living.

Telehealth program is technology integrated with clinical care to change the healthcare delivery, model. Some healthcare providers have already implemented this telemonitoring service that will guide patients through a daily check-up, and also record vital signs and symptoms.

These details will be then sent to a central monitoring system, from where home health agencies will be receiving an alert in case of emergency.

Challenges faced by Home Health

Technology Changes
From Health Monitoring Systems to medication tracking devices, technology is expanding at ever-increasing speed and home health struggles to keep up that pace.

New technology is presenting new methods for providers, and of course, home health agencies to connect with their patients but this can also be problematic. From the cost involved in procuring such technologies to patients perception. Changing legal and regulatory climate around the use of technology in the field of healthcare adds to the problem.

Lack of care continuum
Among long-term care patients, 90 percent of them live in their own homes to avoid hospital environment. Increasing demands due to rising older population makes the delivery model challenging to provide affordable, continuous care and to meet the expected quality parameters.

Adapting to changes in government regulations and practices also influences the style of functioning of the system. Value-based physician reimbursement for improving quality and lack of skilled professionals are some of the areas that need immediate attention.

Employing technology can help in improving care delivery, and admittedly choosing the right solution that meets the needs of the practice is the key to success in the ever-changing healthcare environment.

HealthViewX Care Management Solution allows to create and send customized care plan for individual or group of patients to help manage the health of the whole population. Integrated telehealth feature enables provider to connect with patients quickly and track patient’s health condition remotely.

Complex CCM Codes To Expand Care Opportunities

On November 15, 2016 – the Centers for Medicare and Medicaid (CMS) announced the new changes to Chronic Care Management payment options by adding new codes and key improvements to the existing CCM billing methods and services.

Feedback from providers is the key reason for new codes. These changes are now set to implement on practices starting 2017 with an objective to enhance patient care and ensure hassle-free documentation for billing. Services offered by physicians will be based on the complexity of the patient’s need and will be billed under different CPT codes based on the service provided. Here is a summary of CCM and complex CCM codes.

CCM payment option till 2016

A physician will be paid $42 for 20 minutes of clinical staff time provided to patients with multiple (two or more) chronic conditions per calendar month under CPT 99490. Reimbursement for the provider will be the same if the clinical service time exceeds 20 minutes.

Changes in CCM codes effective from 2017

CMS recognized some patients may have complex chronic conditions and they might need additional care time. So, CMS addressed the need by introducing new codes 99487 and 99489 which will benefit those who need extra care and will also compensate providers with increased reimbursement options through new codes.

  • CCM Code 99490
    Payment has increased from $42 to $43 for 20 minutes of clinical staff time.
  • Complex CCM Code 99487
    60 minutes of CCM service for $94 that includes moderate to high complex medical decision-making.
  • Add-On Complex CCM Code 99489
    This code is to use with 99487. Additional 30 minutes of service will be provided for bill amount $47.

In addition to the CCM codes, there are changes made in the service elements for enhanced care and administrative simplifications on billing.

CCM Service Changes for 2017

Initiating Visit

From 2017, initial visit is required for new patients or patients who have not enrolled their name for CCM services within past twelve months. Payment of $44-$209 to be billed by the billing practitioner for initiating visits.

For initial visit, CMS has introduced a new add-on code G0506 that includes extensive assessment and care planning performed by the billing practitioner beyond the usual efforts. A payment of $64 will be billed for this extensive initiation work- only once per patient per provider.

EHR and Technology requirements

CMS continues to stress on using certified EHR with a standard format (demographics, problems, medications, medication allergies, etc.) to record core clinical information.
It also states that the use of certified technology is no longer required for CCM documentation or care plan for sharing within or outside the network. Frequent access to care document is not required, given that providers have timely information on hand or for individuals providing CCM service after hours.
At the same time, CMS recommends physician to use certified technology as per the conditions of Medicare Physician Fee Schedule (PFS) payment to get points for the Quality Payment Program (QPP)
Beginning 2017, care plans can also be shared through fax as it has created more fuss last year among some providers when shared electronically.

Care Management

From now, the clinical summary is renamed as “continuity of care document(s)” and a care management plan copy given to patient requires no format. Usage of certified technology has been completely removed in this revision.
Beneficiary and caregivers are given the opportunity to communicate with the practitioner, not only through telephone, but also by means of secure messaging, Internet, or through any non-face-to-face communication methods.

24 hours access to care

Patients and caregivers are provided access to any of the physicians or other qualified professionals or clinical staff to make quick contact to address urgent care needs, not just for chronic care needs.
Continuous relationship with a designated member of the care team is improved to schedule quick and routine appointments.

Consent Change

Consent can be either verbal or written, but it must be documented in the patient record and the same should be explained for transparency.

How is Chronic Care Management Evolving?

The Centers for Medicare and Medicaid-recognized the importance of including a sustainable practice to manage care for patients suffering from multiple chronic conditions in the year 2015.
Medicare leveraged Physician Fee Schedule (PFS) options for CCM services offered to patients ailing from chronic conditions.

It’s been over 2 years since the implementation of Chronic Care Management services for patients.
CMS has closely observed the outcomes of those initiatives and has come up with plans that will increase the focus and funding towards the existing Chronic Care Management programs.

Let’s Understand CPT 99490

To be able to differentiate the purpose of the old codes from the new codes, one must understand the conditions for billing under CPT 99490. Chronic Care Management Services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements:

  1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
  2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  3. Comprehensive care plan established, implemented, revised, or monitored

Assumes 15 minutes of work by the billing practitioner per month

What’s new in Complex CCM codes?

The primary limitation of CPT 99490 is the consulting time of 20 minutes, most practices felt the need to increase the consultation time for a patient.
Though CCM services resulted in positive outcomes, the results were far short of objectives.
Thus, they decided to increase the consulting time of CCM with new Complex CCM codes that can be used to provide 60 minutes of consulting in a calendar month and the duration of 60 minutes is billable.

Complex Chronic Care Management services, with the following, required elements:

    1. Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
    2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
    3. Establishment or substantial revision of a comprehensive care plan
    4. Moderate or high complexity medical decision making
    5. 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month

How does the billing work?

A patient must be billed either for Complex Chronic Care Management codes or the already existing Chronic Care Management code.
The same patient should not be included or billed under both the codes, that way there’s more organized workflow for billing and reimbursement.

Reporting Expectations

Chronic Care Management codes CPT 99487, 99489, and 99490 are reported only once in every calendar month by the practitioner who carried out the care management, no more than one claim per month was allowed.
In the case of Complex Care Management, each month a practitioner is expected to review patient’s health condition and classify whether the patient would still be under the procedures of Complex Care Management or the existing Chronic Care Management codes.

This is a crucial practice to establish the health outcome of the patients given the importance and assistance for chronic conditions, in addition to that practitioners are expected to meet the quality metrics that are recommended by CMS.

Implementation of Comprehensive Care Plan at a practice level

New Chronic Care Management codes stress the necessity and induce the interest in creating an individual care plan for each of the patient’s for achieving better health outcomes.
It is important for the healthcare provider to record and assess patient health information at regular intervals.

An electronic form of secure patient information needs to be generated, based on which a physician can come up with a care plan that is required for the patients.
With technology companies extending their influence in healthcare, remote patient monitoring and real-time patient data can be gathered and put to best use. Creation and execution of care plan is one of the primary responsibility of the provider to adhere to quality metrics expected by the CMS.

HealthViewX is in the business of Healthcare IT, we offer a suite of comprehensive IT solutions from Referral Management, Chronic Care Management and a holistic Care Management Platform.

5 Healthcare Trends To Watch Out

The past year was a year of change for the healthcare industry. From the news by late 2016 about how a staggering 95% of US hospitals have participated in Medicare EHR Incentive Program to the ever-increasing cyber-attacks on hospitals systems to CMS rolling out new regulations and rules to further the industry’s transition from fee-for-service-based to a value-based payment model.*

What changes will happen in the industry this year around? The first month of a year is the best time to ponder that question.

Here are 5 trends that we think will create ripples in 2017.

1. Blockchain Will Be Put to Work

Blockchain made a lot of noise last year. So what is blockchain? And, how does it work?

A blockchain is a distributed database that can store any values without repetition even after multiple updates. It stores information in blocks (in databases called records) and each block will have timestamp and link to a previous block.

For example, every time a transaction is made, the transaction data/information will be stored in a new block rather than updating an existing information, and the new block is added to the existing blocks forming a blockchain.

Basically, once data is created, it cannot be altered. The system will encrypt all the data stored and it is impossible for hackers to break into the system.

2. Healthcare Consumerism is on the Rise

Patients fund their health care expenses. Patients’ nowadays act as real consumers and seek for high-quality service for the cost incurred. Earlier patients were pressurized with large deductibles and it turned the table towards hospital providers to provide better care.

The rise in consumerism also increases the digital transformation in healthcare. Patients are now demanding the type of service quality that they are familiar with from other industries. Though digital push rises the care cost, it improves the patient’s engagement levels. The investment made in technology will enhance the digital consumer experience by making it more viable.

3. Telehealth to Serve More

Value-based and patient-centered care has providers’ attention on telehealth technologies. Telehealth service has drastically reduced the readmission rate and the cost of Chronic Care Management.

In addition to that, it has also improved communication after patients are discharged. “The number of Americans receiving virtual medical care is forecast to double, from 15 million in 2016 to 30 million in 2017”, according to American Telemedicine Association.

4. Cloud to Get More Attention

Data storage is still an unsolved puzzle for many providers. Though some opted cloud to improve practice management there were a lot of security concerns. Despite all, most accelerated technology investment of healthcare is expected to be made on Cloud in 2017.

“It wasn’t too long ago that people were skeptical of cloud computing, but today, over 83 percent of healthcare organizations are using cloud technology, according to a HIMSS Analytics Cloud Survey,” says Morris Panner, CEO of Ambra Health.

It is also estimated that the health cloud computing market will grow to 9.48 Billion dollars by 2020, a new report from MarketsandMarkets.

5. Cognitive Computer with Ease Process

The process of healthcare transformation is increasing the number of tasks performed. In the coming years, much time will be spent on understanding and finding ways to leverage the advanced computing system to better the clinical operations. Cognitive computers ease the process of analyzing the unstructured pattern of data.

For example, IBM cognitive machine surfaces insights by analyzing masses of data- personal, medical, practical, pharmaceutical, etc. Adapting such innovative technology in healthcare helps hospitals function more effectively.

Healthcare always strives to deliver good quality of service at lower costs by including technology elements such as telemedicine, cloud, analytics, cyber security, remote patient monitoring and also by trying out newer technology solutions to bring out the better outcome.

* “Hospitals Participating in the CMS EHR Incentive Programs”-

* “Ransomware: See the 14 hospitals attacked so far in 2016”-

Problems With Medical Referrals in the US

During the last two decades, the number of medical referrals in the US has dramatically increased. The healthcare system has more specialists and specialties than before but unfortunately, no parallel growth can be cited for general health care quality or efficiency in patient management. The purpose of medical referrals is to ensure that the patients receive the right type of care from a specialist for a specific condition.

Here are the reasons why all those referrals are going down the drain, literally.

1. Inappropriate Referrals
2. Outdated Technology
3. Insufficient Data
4. Delayed care

Inappropriate Referrals:

It is estimated that nearly 20 million referrals are made in the US every year which are considered to be clinically inappropriate (according to an article that appeared in the HIT consultant blog -“19.7M Clinically Inappropriate Physician Referrals Occur Each Year”). Clinically inappropriate referrals are those referrals which are not made to the right Specialist. PCPs make inappropriate referrals due to the physician’s lack of information about the specialist, referring to offices about the lack of information on available specialists and personal relationships between the providers.

When an inappropriate referral is made the primary provider will have to re-refer the patient to a more appropriate provider or the patient will end up receiving care from an inappropriate provider; in either of the cases, the patient will get poor outcomes and increased cost.

Outdated Technology

Referrals made by a provider to a specialist sometimes could fall through the “cracks” in the referral process. This could vary from practice to practice; some due to faults in referral procedures or ambiguity of the processes.

One recurring problem with referral procedures is with the use of technology or lack thereof. HIPAA regulations have mandated certain standards for the use of technology to transfer patient data. For example, it is against the regulations to use providers’ personal email to send or receive patient data, HIPAA has also mandated against the use of fax which is vulnerable in the case of data theft.
On top of being insecure, these technologies are not capable of supporting modern healthcare requirements including instantaneous communication, secure chat and exchanging data.

Insufficient Data

Primary care and specialist care are poorly integrated into a single system, the lead cause of this is lack of data. There are no means to transfer data between specialist or primary provider. The specialist is always making the fresh diagnosis without knowing the care history of the patient while the primary provider is unaware what kind of care his/her patient has earlier received.

Delayed Care

Referrals are (traditionally) a slow and time-consuming process. The primary care provider with limited information about the available specialists finds it hard to shortlist an appropriate specialist. The provider has to go back and forth to choose one out of the various specialists. Between the primary provider’s preference and the specialist’s availability, the patients experience long waiting hours and would finally decide to meet another provider out of the network.

The wait to see a primary care provider, the wait to get referred and the wait till specialists appointment plus the possibility that this process may have to be repeated leads to long delays to even receive most basic care.

Primary and specialist care coordination is an important aspect of the healthcare continuum. Providers should create and evaluate a referral process which would ensure maximum security of the information shared, minimum resistance to sharing patient data and possibly reduce the time delay in the referral process.

HealthViewX Referral Management Solution is a web-based, multi-channel referral management platform. Providers can send and receive a referral, share patient related information and track referral progress through one window making the referral workflow seamless and effortless.