Tag Archives: CMS

HEDIS: Healthcare Effectiveness Data and Information Set

HEDIS is a set of performance measures that are used to compare health plan performance and measure the quality of health plans. These measures were created by the National Committee for Quality Assurance (NCQA). About 90% of health plans use HEDIS as a standard to measure the performance of their plan. The data is tracked from year to year to measure the performance of the health plan and thus provides information regarding the population served.

The data that is collected is used to monitor the health of the general population, evaluate treatment outcomes, etc., and the data is collected through administrative, hybrid, and survey methods.

HEDIS Measure Domains:

About 95 HEDIS measures are categorized under the following six “domains of care”.

Effectiveness of Care

  • Controlling High Blood Pressure
  • Care for Older Adults 
  • Haemoglobin A1c Control for Patients With Diabetes 
  • Blood Pressure Control for Patients With Diabetes
  • Eye Exam for Patients With Diabetes
  • Breast Cancer Screening
  • Colorectal Cancer Screening

Access/Availability of Care

  • Adults’ Access to Preventive/Ambulatory Health Services
  • Utilization and Risk Adjusted Utilization.

Experience of Care (CAHPS) 

  • CAHPS Health Plan Survey 5.1H, Adult Version
  • Utilization and Risk Adjusted Utilization

Utilization and Risk-adjusted Utilization 

  • Well-Child Visits in the First 30 Months of Life
  • Child and Adolescent Well-Care Visits

Health Plan Descriptive Information

  • Language Diversity of Membership
  • Utilization and Risk Adjusted Utilization

Measures Collected Using Electronic Clinical Data Systems

  • Childhood Immunization Status
  • Breast Cancer Screening
  • Depression Screening and Follow-Up for Adolescents and Adults

How is data collected for HEDIS?

Health plans collect and report performance data about specific services and types of care to NCQA. NCQA rates health insurance based on 90-plus measures.

HEDIS data is collected through three methods: 

  1. Administrative data: Data collected from office visits, hospitalizations, and pharmacy data
  2. Hybrid data: It’s a combination of administrative data from claims as well as from patient’s medical records 
  3. Survey data: This is data collected through survey questionnaires from members.

Why do HEDIS scores matter?

HEDIS scores are critical for health care planning. HEDIS scores help payers understand the quality of care their members receive for chronic and acute conditions. The better the score, the more effectively the payer competes with other payers in the market.

Benefits of HEDIS measures:

  • It helps health plans assess the quality and variance of health care provided to enrollees.
  • It determines how the plan is best for chronic disease management and preventive care. 
  • The use of preventive screening measures helps to improve patient outcomes and reduce healthcare costs
  • Quality interventions are based on closing gaps in care and expanding preventive services such as vaccinations, pap smears, mammograms, and treatment for hypertension or cholesterol.
  • Star ratings enable providers to measure the success of their improvement initiatives

Effects of HEDIS on Reimbursement:

CMS has directly tied reimbursement of medical costs to patient outcomes. As a result, health insurance providers face the challenge of bridging coverage gaps and improving quality. By focusing on quality results, members can maximize their benefits and ultimately make better use of limited resources. 

HEDIS is recognized as the highest standard of reimbursement by health care providers and payers. Health care plans take HEDIS tests and quality measures seriously because they know that money is at stake. Leaders need to be more aware of the importance of organizations continuing to engage in all quality improvement activities.

Ultimately, CMS penalizes health plans if they underperform for more than three years. HEDIS as a whole is changing the company’s understanding of the importance of measuring quality, a fundamental concept underlying performance-related quality initiatives.

Effects of HEDIS on gaps in care

HEDIS measures can help identify gaps in care for participants who have not been screened for breast cancer or who have not been vaccinated against HPV. This can affect your quality score. Improving Star and HEDIS performance requires closing the gap. These gaps can be filled by reaching these participants through home testing kits, home health care, and screening visits.

Why is HEDIS important to providers?

  • Ensure timely and appropriate care for their patients.
  • Help identify and address gaps in patient care.
  • As HEDIS rates rise, providers are able to capture maximum or additional revenue through a pay-for-quality, value-based service, and pay-for-performance model. 

Why is HEDIS important to payers?

  • HEDIS scores help health plans understand the quality of care provided to people with chronic and acute conditions. 
  • Helps identify gaps in health network performance and care delivery 
  • Helps improve patient outcomes and reduce care costs through preventive services 
  • HEDIS identifies public health impacts such as heart diseases, cancer, smoking, and asthma which provides useful data on health issues. 
  • Care is provided to help identify and treat at-risk groups who have not completed immunizations, dental care, screenings, etc.

NCQA Health Plan Rating vs Medicare Star Ratings:

The Centers for Medicare and Medicaid Services (CMS) uses a five-star rating system to rate how well Medicare Advantage (MA) health plans (Parts C and D) and providers serve their members. Assessment results are based on the implementation of the plan, the quality of care provided, and customer service. Ratings range from 1 to 5 stars. 5 is the highest score for excellent performance, and 1 is the lowest score for poor performance.

Both the NCQA Health Plan Rating (HPR) and the Medicare Star Rating are used to assess health insurance quality and performance, and both rate and report plan performance. The goal of HPR and star ratings is to provide the plan with a metric to assess its current operational status. This allows us to ensure the quality of our plans so that consumers can choose a quality health plan that meets their needs.

HEDIS and Star ratings are important because they represent the effectiveness of patient care provided by healthcare organizations, and HEDIS and Star ratings decrease when there are gaps in care. Another reason HEDIS and Stars need to maintain high ratings is for reimbursement purposes. Healthcare organizations with a lower rating are not eligible for bonus payments and are subject to fines.

CMS’s Journey To Value-Based Care

Most people think of CMS (Centers for Medicare & Medicaid Services) as an insurance company that covers individual services provided by physicians, FQHCs, hospitals, and other health care providers. Some people even think of it as a policy-writing agency for Medicare. It is true that CMS reimburses providers for services to millions of individual beneficiaries. However, since the Affordable Care Act came into action in 2010, CMS has been developing focused payment strategies that shift from fee for services to value-based care and a focus on population health. 

Today, CMS’s second-highest strategic priority is prevention and population health. To this day, the agency is engaged in numerous activities to promote effective prevention of chronic diseases and not just its treatment.

In 2011, the federal government reported that fewer than half of all adults aged 65+ were regular in checking the core set of recommended preventive services. The Affordable Care Act took a big step towards improving the access to preventive care by eliminating out-of-pocket costs for these preventive services in most insurance markets. This resulted in guaranteed access to preventive services like diabetes screening and cervical cancer screening to almost 137 Million Americans without cost-sharing.

Despite improved access to care, the use of preventive services among seniors with traditional Medicare coverage has not changed significantly. There are several hindrances that inhibit the greater uptake of preventive services. A 2014 survey reveals that only 43% of adults were aware of the new clinical preventive benefits provided by the Affordable Care Act. Of those who were aware of the services, 18% cited cost as a barrier, even though the Affordable Care Act eliminated co-payments for preventive services. 

Another obstacle is that many Americans believe that preventive services are not important. Thus, even though many cost barriers have been removed, many Americans still might not perceive preventive services as valuable to their health and well-being. This mindset needs to change. 

Shifting the paradigm of preventive care requires CMS and other payers to provide incentives beyond individual services to broader value-based and lifestyle interventions that can change population outcomes. To address this issue, CMMI has developed 2 payment models:

(1) The Million Hearts Cardiovascular Risk Reduction Model:

Million hearts model

This model associates payment with population-based risk reduction. It is expected to reach over 3.3 million Medicare fee-for-service beneficiaries and involve nearly 20,000 health care practitioners by December 2021.

(2) The Medicare Diabetes Prevention Program:

Medicare Diabetes Prevention Program

This program ties payments to the achievement of weight loss through evidence-based lifestyle intervention.

CMS collaborated with sister agencies such as the Centers for Disease Control and Prevention (CDC) to develop these population health models, and they are good examples of how CMMI is using the Medicare payment structure to improve prevention and population health.

These path-breaking innovations offer an opportunity for CMS to test payment models that emphasize payment for population health outcomes rather than just individual outcomes, with the goal of better care and a healthier population.

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298510/#bibr11-0033354916681508

https://innovation.cms.gov/innovation-models/million-hearts-cvdrrm#:~:text=The%20Million%20Hearts%C2%AE%3A%20CVD%20Risk%20Reduction%20Model%20is%20expected,and%20end%20by%20December%202021 

CMS expands Telehealth Services to Deliver Care Safely during COVID-19 and Beyond

During the COVID-19 pandemic, CMS has taken the necessary steps to make it easier to provide quality care through telehealth services. This unprecedented action by CMS has encouraged healthcare providers to adopt and use telehealth as a way to safely provide care to their patients in situations like medication consultation, eye exams, nutrition counseling, behavioral health counseling, and routine health check-ups like annual wellness visits. Past data have shown telehealth to be an effective medium for patients to access healthcare providers especially for managing chronic conditions like diabetes, asthma or to obtain mental health counseling.

Advantages of CMS changes to Telehealth:

telehealth reimbursement codes

Telehealth services made permanent post-COVID-19:

CMS has announced that 60 of the 144 telehealth services that were newly offered during the pandemic will become permanent. This includes services for cognitive assessment, psychological and neuropsychological testing, and custodial care services for established patients.

virtual healthcare

They have also finalized the decision that direct supervision in telehealth visits can be provided with interactive audio and video technology through the end of the year until December 2021. 

 

CPT Code

Services

Description

77427

Radiation management

It is reported once for every five fractions or treatment sessions regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days.

90853

Group psychotherapy

Group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

90953

End-stage renal disease, one visit per month, ages 2 and younger

End-stage renal disease (ESRD) related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, etc.

90959

End-stage renal disease, one visit per month, ages 12-19

End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth 

90962

End-stage renal disease, one visit per month, ages 20 and older

With 1 face-to-face physician visit per month

92057

Speech/hearing therapy

Treatment of speech, language, voice, communication, and/or auditory processing disorder, individual

92521

Evaluation of speech fluency

Evaluation of speech fluency (e.g., stuttering, cluttering)

92522

Evaluation speech production

Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 

92523

Speech sound language comprehension

Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria)

92524

Behavioral quality voice analysis

Behavioral and qualitative analysis of voice and resonance.

96130

Psychological test Evaluation Phys/qhp 1st

Psychological testing evaluation services by a physician or other qualified healthcare professional, including the integration of patient data, interpretation of standardized test results and clinical data

96131

Psychological test evaluation phys/qhp ea

Providers should now use CPT code 96130 to bill for the first hour of psychological testing evaluation services and 96131 for each additional hour

96132

Neuropsychological testing evaluation phys/qhp 1st

Neuropsychological testing evaluation services by physician or other qualified healthcare professional, including integration of patient data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning and report, and interactive feedback to the patient, family member(s) or caregiver(s), when performed; first hour

96133

Neuropsychological testing evaluation phys/qhp ea

The first hour of neuropsychological evaluation is billed using 96132 and each additional hour needed to complete the service is billed with code 96133

96136

Psychological and neurological testing phy/qhp 1s

Psychological or neuropsychological test administration/scoring by physician or other qualified healthcare professional, two or more tests, any method; first 30 minutes

96137

Psychological and neurological testing phy/qhp ea

Similar to 96136. This code is used for each additional hour.

96138

Psychological and neurological tech phy/qhp ea

Psychological or neuropsychological test administration/scoring by technician, two or more tests, any method; first 30 minutes

96139

Psychological and neurological testing tech ea

Similar to 96138. 

 97110

Therapeutic exercises

Foundational, occupational therapy exercises that are designed to improve a patient’s strength, range of motion, endurance, or flexibility.

97112

Neuromuscular re-education

Specific exercises or activities performed and for what purpose, neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, and/or posture.

97116

Gait training therapy

Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing). 

97161

Physical therapy evaluation 

Physical therapy evaluation of low complexity, 20 min

97162

Physical therapy evaluation 

Physical therapy evaluation moderate complexity, 30 min

97163

Physical therapy evaluation 

Physical therapy evaluation moderate complexity, 30 min

97164

Physical therapy evaluation

Physical therapy re-evaluation establish plan care

97165

Occupational therapy evaluation 

Occupational therapy evaluation low complexity, 30 min

97166

Occupational therapy evaluation 

Occupational therapy evaluation moderate complexity, 45 min

97167

Occupational therapy evaluation 

Occupational therapy evaluation high complexity, 60 min

97168

Occupational therapy 

Occupational therapy re-evaluation establish plan care

97535

Self-care management training

Direct one-on-one supervision and instruction regarding activities of daily living related to the patient’s health and hygiene.

97750

Physical performance test

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.

97755

Assistive technology assessment

This procedure is used by the provider to assess the suitability and benefits of technological interfaces that will help restore, augment, or compensate for existing functional ability in the patient.

97760

Orthotic management and training 1st en

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.

97761

Prosthetic training 1st enc

Prosthetic training, upper and/or lower extremities, initial prosthetic encounter, each 15 minutes

99217

Observation care discharge

This code is used to report all services provided to a patient discharged from outpatient hospital “observation status” if the discharge is on a date other than the initial date of “observation status

99218

Initial observation care

The first visit of the patient’s admission for outpatient hospital observation care by the Admitting/Supervising Physician or Other Qualified Healthcare Professional. Typically, 30 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99219

Initial observation care

Similar to 99218 but, 50 minutes are spent at the bedside and on the patient’s hospital floor or unit.

99220

Initial observation care

Similar to 99218 but, 70  minutes are spent at the bedside and on the patient’s hospital floor or unit.

99221

Initial hospital care

Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician.

99222

Initial hospital care

Similar to 99221

99223

Initial hospital care

Similar to 99221

99234

Observation/hospital same date

Observation or inpatient care, are used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99235

Observation/hospital same date

Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99236

Observation/hospital same date

Observation or inpatient care is used when the patient is placed in observation status or admitted to inpatient status and then discharged on the same date.

99238

Hospital discharge day

Used when time spent is less than 30 minutes on the discharge process in face-to-face evaluation.

99239

Hospital discharge day

Used when time spent is greater than 30 minutes on the discharge process in face-to-face evaluation.

99281

Emergency department visit

Requires these 3 key components: A problem-focused history; A problem-focused examination; and Straightforward medical decision-making. Usually, the presenting problem(s) are self-limited or minor.

99282

Emergency department visit

Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.

99283

Emergency department visit

Requires these 3 key components: An expanded problem-focused history; An expanded problem-focused examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of moderate severity.

99284

Emergency department visit

Requires these 3 key components: A detailed history; A detailed examination; and Medical decision-making of moderate complexity. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

99285

Emergency department visit

Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

99291

Critical care first hour

It is used to report the services of a physician providing full attention to a critically ill or critically injured patient from 30-74 minutes on a given date

99292

Critical care additional 30 mins

Code 99292 (critical care, each additional 30 minutes) is used to report additional block(s) of time, of up to 30 minutes each beyond the first 74 minutes of critical care.

99304

Nursing facility care initial

The problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.

  99305

Nursing facility care initial

The problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.

99306

Nursing facility care initial

The problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.

99315

Nursing facility discharge day

99315 is for discharge day management 30 minutes or less

99316

Nursing facility discharge day

This code is for discharge day management over 30 minutes

99327

Domiciliary or rest home visit new patient

Domiciliary or rest home visit for the evaluation and management of a new patient. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99328

Domiciliary or rest home visit new patient

Code used for Evaluation and Management / Domiciliary, rest home (boarding home) or custodial care services. The general guidance for this code is that it is used for new patient assisted living visits, typically 75 minutes. 

99334

Domiciliary or rest home visit established patient

This code 99334 is used to reflect the domiciliary or rest home visit for the E/M of an established patient

99335

Domiciliary or rest home visit established patient

Similar to 99334

99336

Domiciliary or rest home visit established patient

Similar to 99334

99337

Domiciliary or rest home visit established patient

Domiciliary or rest home visit for the evaluation and management of an established patient. Usually, the presenting problem(s) are moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family

99341

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 1 new patient home visit.

99342

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 2 new patient home visit.

99343

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 3 new patient home visit.

99344

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home. Level 4 new patient home visit.

99345

Home visit new patient

Home services are provided in a private residence.  A home visit cannot be billed by a physician unless the physician was actually present in the beneficiary’s home.Level 5 new patient home visit.

99347

Home visit established patient

Home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components.  A problem-focused interval history; a problem-focused examination; and straightforward medical decision making. Typically, 15 minutes are spent face-to-face with the patient and/or family.

99348

Home visit established patient

Similar to CPT Code 99348. Typically, 25 minutes are spent face-to-face with the patient and/or family.

99349

Home visit established patient

Similar to CPT Code 99348. Typically, 40 minutes are spent face-to-face with the patient and/or family.

99350

Home visit established patient

Similar to CPT Code 99348. Typically, 60 minutes are spent face-to-face with the patient and/or family.

99468

Neonatal critical care initial

Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger. 

99469

Neonatal critical care initial

Services of directing the inpatient care of a critically ill neonate or infant 28 days or younger. 

99471

Pediatric critical care initial

Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

99472

Pediatric critical care initial

Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age

99473

Self-measurement of blood pressure at home education/training

Code 99473 represents the work of training the patient and calibrating the device,

99475

Pediatric critical care ages 2-5 initial

Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

99476

Pediatric critical care ages 2-5 subsequent

Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age

99477

Initial day of hospital care for neonatal care

Initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services.

99478

Ic low-birthweight infant

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( < 1500 gm)

99479

Ic low-birthweight infant < 1500-2500 g subsequent

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant( 1500 gm-2500g)

99480

Ic infant pbw 2501-5000 g subsequent

Intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant(2501g-5000g)

99483

Assessment and care plan cognitive impairment

Assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home

The ongoing pandemic has resulted in an increased workload for healthcare providers across the country. Incorporating telehealth software into an existing practice can allow providers to virtually connect with patients. This can relieve the strain on practice while introducing an additional revenue stream.

HealthViewX Telehealth/Telemedicine Platform helps health systems to align clinical, financial, and operational goals by providing high-quality remote care and enhancing patient-physician collaborations.

References: https://www.beckershospitalreview.com/telehealth/cms-adds-85-more-medicare-services-covered-under-telehealth.html

Earn from Medicare’s Chronic Care Management Program! CCM made simple!

Chronic Care Management Services are delivered to Medicare beneficiaries with two or more chronic conditions with a goal of improving health and quality of care for high-need patients. As population ages, FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. face the daunting challenge of improving quality of care for chronically ill patients while containing costs.

The Centers for Medicare and Medicaid Services (CMS) says about 93% of total Medicare spending is on beneficiaries with multiple chronic conditions. Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions are more likely to present in emergency rooms, and be admitted than others.

In spite of the need for proactive care for Chronic Care Management Patients, a lot of the providers are still underutilizing this benefit. There are several reasons why providers like FQHCs, RHCs, ACOs, Hospitals, individual practitioners, etc. have chosen to leave it on the table.

Complicated Process:

There are several rules physicians and practices have to follow in order to qualify for CCM reimbursement. CMS has set rules right from enrolling Medicare patients up to the necessary documents that have to be furnished for CCM reimbursement. Other mandatory requirements include providers offering CCM service, should have access to patient’s health records, provide 24/7 access to care, provide care plans, and patients be able to reach providers to meet urgent care needs.

Time Consuming and involves additional costs:

Many providers feel offering CCM service is a time-consuming effort, and requires additional staffing. They find it difficult to document each of these and also provide quality care for their patients. Providers feel there is an increased administrative burden to managing and tracking CCM services, and it also involves additional cost.

Patients Consent:

Providers must identify Medicare eligible patients, explain CCM services and get consent to enroll the patient and start the service. Providers must explain the required information in detail where the patient can either accept or decline the service. 

Wait and See Approach:

Providers  want to first see if the approach is effective before deciding to opt for it. Many providers and physicians wait to see if other providers who opted to provide the service have success with reimbursement before committing to participation in the program.

HealthViewX makes Chronic Care Management process easier with the below features and makes reimbursement simple:

Automated Documentation for CMS Auditing

HealthViewX automates and streamlines the end-to-end CCM process. Integrates with softphones to accurately record the time spent on each call. It easily helps generate reports as per CMS requirements. 

Comprehensive Care Plan

Structured care plans are essential to help organize coordination of actions for proper patient progression and self-management. The solution helps create condition-specific, personalized and comprehensive care plans for each patient including tasks and goals for both the patient and care coordinator track for better care coordination. Simplifies and streamlines workflow to guide tele-nurses in creating care plans. 

HIPAA Compliant

HealthViewX CCM follows HIPAA compliance requirements and guidelines. The solution lets you define the access, have user-specific access conditions, and provides secure access to patient records.

Analytics and Dashboard

Gives detailed actionable insights for better care coordination. Data can be visually represented and users can gather detailed information by clicking the desired data. The dashboard also displays the follow-up reminders that can be set-up by the user against each patient.

Take this simple step to improve health outcomes and reduce costs for patients with multiple chronic care conditions.

Schedule a demo and talk to HealthViewX Solution experts today to discuss the CCM solution. Or simply outsource your CCM services. HealthViewX also provides end-to-end CCM services through our network of seasoned RNs and CMAs that enable you to increase your monthly reimbursements without incurring any additional cost of hiring additional staff or investing in technology solutions.

Understanding the scope of Chronic Care Management and what is required to make it profitable

Approximately 71% of the total healthcare spend in the United States is associated with care for Americans with more than one chronic condition. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending.

It is said that a large percentage of these expenses are associated with acute care and emergency visits that could be prevented by earlier intervention. Patients who have multiple chronic conditions require ongoing medical attention. Putting further emphasis on health programs with an eye towards preventing and controlling chronic disease is one of the ways to address such costs.

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.

What Physicians need to understand?

Medicare’s Chronic Care Management program has a primary clinical goal which is improving the health of Medicare patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and who are at significant risk of death, acute exacerbation/decompensation, or functional decline. In addition to understanding the service-level parameters, pay levels, CCM codes.

PCP’s and other health organizations who provide CCM services need to understand how to effectively bill for CCM in order to profitably achieve that goal.

Some of the basic preconditions that providers must satisfy are:

  • the provider is required to complete an initial face-to-face visit
  • obtain verbal or written consent from the patient, and  develop a comprehensive care plan in the electronic health record
  • provide 24/7 access to care
  • use a certified EHR to aggregate all patient health information
  • establish continuity through a designated care team member who works with the patient to implement a dynamic plan that spells out the patient’s key prevention and treatment goals and strategies

Who all can provide CCM services?

Additionally to physician offices, Chronic Care Management Services can be provided by

  • Federally Qualified Health Centers
  • Rural Health Clinics
  • Critical Access Hospitals

And the following healthcare professionals can bill for CCM services

  • Physicians
  • Physician Assistants
  • Nurse Practitioners
  • Certified Nurse-Midwives
  • Clinical Nurse Specialists

Non-physicians must legally be authorized and qualified to provide CCM in the state in which the services are furnished.

Why provide Chronic Care Management Services?

It benefits both providers and patients. Patients will receive better-coordinated care thereby preventing hospitalization and re-admissions. Providers will not only receive payments for providing care but also improve practice efficiency, compliance, patient satisfaction, and health outcomes. Practices, large providers, and health systems can add net new recurring monthly revenue. 

How do physicians and other providers document the CCM services that are provided?

Some practices do the tracking manually, while some of the practices have CCM documentation built into their EHR’s. Other practices implement specialized CCM software to track time and ensure all the CCM requirements are met. Some of the CCM software has the ability to track not only the documentation but also send reminders or notifications to the patient, provider and other healthcare professionals involved in patient care. 

How to make CCM profitable?

Chronic care management requires 24/7 access to care. Practices take different approaches to meet this requirement to provide better care coordination. Some practices hire additional staff and some opt for a solution to automate the end-to-end process to cut down on additional staff expenses. Considering healthcare IT will not only cut down on additional expenses but will also make CCM more effective and efficient.

Talk to HealthViewX solution experts to understand more about HealthViewX CCM solution and make your CCM profitable.