Dismantling the Hurdles of Chronic Care Management

Using the right Chronic Care Management company facilitates improving patient outcomes

In 2011, The Institute of Medicine’s (IOM) landmark publication “Crossing the Quality Chasm” sent shockwaves through the healthcare system by raising serious doubts about the quality of healthcare in the United States.  Since then, reimbursement models have undergone a paradigm shift from compensating quantity to reimbursing quality.  A prime example of this is payment for Chronic Care Management (CCM) services.  The goal of CCM is to improve the quality of care provided to patients with chronic conditions.  In the CCM reimbursement matrix, providers receive revenue for using care plans to provide counseling, education, and support to patients between office visits.

Sylvia Burwell, who was Secretary of the U.S. Department of Health and Human Services (HSS) during the Obama administration, expressed the organization’s aim “to move the Medicare program, and the healthcare system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.”  To move toward this goal, HHS published a new objective to have 50% of Medicare reimbursement tied to quality of care by the end of 2018.

New Billing Codes for CCM Services

As part of the quality initiative, the Centers for Medicare and Medicaid (CMS) introduced Medicare Current Procedural Terminology (CPT) code 99490 for CCM services in 2015. In 2017, two additional CPT codes were added for complex CCM services. Although reimbursement using CPT codes falls into the traditional fee-for-service payment model, CCM services are an important step toward HHS’ goal because the objective of CCM, by nature, is better coordinated and higher quality care.

The CPT codes that are currently available for CCM services are:

• 99490 (basic CCM)
• 99487 (complex CCM)
• 99489 (complex CCM with additional time accrued)

The table below provides additional guidelines on using each CPT code.

High Potential for Improved Outcomes and Lower Cost

Providing CCM services has the potential to dramatically improve the healthcare outcomes of millions of Americans.  According to The Centers for Disease Control (CDC), chronic disease causes 7 out of 10 deaths in the U.S. and accounts for 86% of America’s healthcare cost.

For a provider to bill for CCM services for a particular patient, the following requirements must be met:

• The patient has 2 or more chronic conditions that are expected to last at least 12 months.
• The patient’s chronic conditions place him at risk of death or acute exacerbation. 
• There is an established, comprehensive care plan for the patient.
• Only 1 provider per patient per month can be paid for CCM services.
• The billing provider has seen the patient within the past calendar year.
• The patient has consented to receiving CCM services.
• The consent is documented in the patient’s medical record and includes the following:
  • Information on the out-of-pocket cost associated with CCM services.
  • Acknowledgement that health information may be shared with other providers.
  • Recognition that the patient may discontinue CCM services at any time.

Obstacles to Delivering CCM Services

Despite HHS’ attempt to push quality to the forefront of the U.S. healthcare system, and the desperate need for CCM, CCM remains a woefully underutilized service.  Since establishing CCM services in 2015, CMS reports that less than 15% of eligible individuals actually received services by the middle of 2016.

The lack of participation is remarkable given the potential revenue for physician groups.  For example, if a practice enrolls 1,500 patients in its CCM program and receives $40 per month in reimbursement per patient, this equals a potential revenue of $720,000 per year.  This is especially relevant for practices that provide care to Medicare patients, which offers lower reimbursement than commercial insurance.

Seeing the obvious financial benefit to providing CCM services and the small percentage of eligible patients who receive those services, it’s clear that physician groups are facing obstacles to implementing CCM programs. The 2015 National Chronic Care Management Survey reported that the primary obstacles to delivering CCM services are:

• Regulatory complexity
• Low reimbursement
• Lack of capital
• Limitations of electronic health records (EHRs)  

To address the regulatory complexity and low reimbursement, CMS made the following changes in 2017:

• New billing codes (99487 and 99489) were added for complex CCM services.
• For a patient seen by his or her provider within the past 12 months
  1. Written consent for CCM services is NO LONGER required.
  2. Verbal consent must be documented in the patient’s medical record.

Lack of resources and limitations of Electronic Health Record (EHRs) are also hindering widespread implementation of CCM.  Lack of resources refers not only to the financial capital needed to develop a new program, but also has to do with the knowledge base, physician participation, and clinical staff required to make the program a success.  The 2015 National Chronic Care Management Survey also found clinics that have a higher number of ancillary staff, a team-based approach to care, and physician buy-in were more likely to offer CCM services.

Limitations of EHR systems to meet the requirements for CCM billing directly relate to the specified core technology requirements of CCM providers.  CMS requires CCM providers to attest to the following in order to receive reimbursements for CCM services:

1. Using certified EHR technology
2. Maintaining and updating an electronic care plan at least annually
3. Facilitating care coordination by having the ability to electronically transmit a summary of care record

Although CMS reports that two thirds of Medicare providers use certified EHR technology, limitations of EHR systems continue to be a barrier to implementing CCM programs.  Incorporating the use of electronic care plans lags behind other healthcare IT initiatives.  Furthermore, there is a significant disparity in certified EHR use among large versus small practices.  According to a 2016 HHS study,  barely 50% of practices with fewer than 10 providers are using certified EHR technology.  This correlates with the fact that small practices are less likely to implement CCM programs.  

Choosing a Chronic Care Management Company to Facilitate Services

A handful of software platforms have emerged to help healthcare facilities provide CCM services.  If your organization is considering implementing a CCM program, you should consider:

1. Can the chronic care management software interface with your EHR(s)?
2. Does the software company provide adequate training to users?
3. How easy is it to build and modify care plans within the platform?
4. Does the software record phone calls, notes, messages and other documentation for the encounter?
5. Are you able to generate a billing report within the application that includes time spent on CCM?
6. Does the application interface with an (Revenue Cycle Management) RCM system?

At Bridge Patient Portal we are dedicated to patient engagement and improving patient outcomes.  We believe that optimizing CCM services meets both of these objectives. On our site, learn more about  the Bridge Patient Portal Chronic Care Management Software.