Your Care … Continued.

Gen By Gen Health can grow your physician-patient relationship between visits. Our Chronic Care Management solutions continue your care outside the office to ensure compliance and improve health literacy with logistic coordination and wellness coaching – improve health outcomes, patient satisfaction, and increase revenue with no additional resources or cost to your practice.

Chronic Disease Burden in the United States

%

MEDICARE beneficiaries have a 2+ chronic condition

%

Patients with chronic conditions were readmitted within 30 days

%

of national healthcare costs overall

%

Americans die from chronic diseases

Examples of Care delivered by GenbyGen’s Nurses to your Patients

Medication Adherence, Refills, & Delivery Coordination

Risks

Depression and Fall Risks Screening

Scheduling Office Visits and Annual Wellness Visits

Referral Management

Referral Management

Patient Education

Patient Education and Wellness Coaching

Insurance Coordination & Benefits Optimization

How it Works?

Gen By Gen delivers successful and customizable Chronic Care Management (CCM) services by following these 5 simple steps.

Get in touch with our CCM Expert

A Financially Sustainable Solution

Estimate your Annual CCM/RPM Revenue

Physicians can earn $200,000+ per year through Chronic Care Management (CCM) and Remote Patient Monitoring (RPM)

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Our Patients’ Case Studies

Koyrun, H no longer remains behind the preventive care and continues to get all the care she is past due on.

Koyrun, H

Age:  64 years old

Concerns: Hypertension, Type II Diabetes, Osteoporosis, Sciatica, Leg Pain of Unknown Cause, Back Pain

Time Since Enrollment: 5 months

Our Success in Numbers

30 PT Appointments

across two PT specialties in 5 months.

4 Preventive Health Screenings

across all body systems.

Saved $600/month

on home health cost.

Edward, R continues to live in an Assisted Living facility and now has a team dedicated to his success with mobility and movement.

Edward, R

Age:  85 years old

Concerns: Parkinson’s Disease, Vascular Disease, Peripheral Neuropathy, Overactive Bladder, Chronic Back Pain

Time Since Enrollment: 3 months

Our Success in Numbers

4 Appointments

across four specialties in 6 months.

Saved $600/mo

on additional costs from assisted living facility by hiring private pay home health aid.

Saved $30/mo

from a duplicate medication detected during medication analysis.

Ahmed, M continues to live independently in his own home. The family now has more peace of mind, and a better understanding of his disease progression

Ahmed, M

Age:  77 years old

Concerns: Parkinson’s Disease, Gait Instability, Dysphagia

Time Since Enrollment: 6 months

Our Success in Numbers

24 PT Appointments

across two PT specialties in 6 months.

4 Preventive Health Screenings

across all body systems.

Saved $900/mo

On drug and home health cost.

Frequently Asked Questions

What is Chronic Care Management?

The Centers for Medicare & Medicaid Services (CMS) offers the Chronic Care Management (CCM) program to provide reimbursement for non-face-to-face care management services for patients with multiple chronic conditions. The program aims to:
  • Improve health outcomes
  • increase patient satisfaction
  • Reduce healthcare costs for patients with chronic conditions
The program includes the following services:
  • Care Coordination and Management: Coordinating and communicating with other healthcare providers to ensure appropriate care and tracking patient progress.
  • Care Planning: Developing a tailored care plan that is adjusted as needed.
  • Patient Education and Self-Management Support: Providing education and resources to promote self-management.
  • Medication Management: Reviewing medications and ensuring correct usage.
  • Care Transitions: Facilitating communication and coordination between patients, family members, and caregivers during healthcare setting transitions.
  • Follow-up and Monitoring: Ongoing support to maintain patient health and manage conditions over time.

    Eligible Providers

    CCM services can be provided by:
    • Physicians
    • Nurse Practitioners
    • Physician Assistants
    • Nurses
    • Care Managers

Who is eligible for Chronic Care Management (CCM)?

Chronic Care Management (CCM) is a program offered by the Centers for Medicare & Medicaid Services (CMS) and is available to patients who have Medicare Part B coverage and have at least two or more chronic conditions. The chronic conditions that qualify for CCM services are those that have been or are likely to last at least 12 months and require frequent medical attention and self-management. Examples of chronic conditions that qualify for CCM services include:

CCM services include:

  1. Diabetes
  2. Heart failure
  3. Coronary artery disease
  4. Chronic obstructive pulmonary disease (COPD)
  5. Hypertension
  6. Cancer
  7. Depression and other mental health conditions
  8. Asthma
  9. Chronic kidney disease
  10. Arthritis
  11. Osteoporosis
  12. Alzheimer’s disease
  13. Parkinson’s disease

To be eligible for CCM services, patients must also be seen by a primary care provider or a care manager at least once every 90 days and have a care plan established with the patient or their caregiver.

It is important to note that this program is only for patients with Medicare Part B coverage.
Those who have Medicare Advantage plans (Medicare Part C) are not eligible for this program. Additionally, the patient should not be in an inpatient setting, hospice, or receiving home health services. If a patient is in an inpatient setting, then other programs such as Transitional Care Management (TCM) are more appropriate.

What are the applicable reimbursements for CCM in 2024?

2024 CCM Reimbursement Rates
99490 The first 20 minutes of clinical chronic care management services for patients with two or more chronic conditions are expected to last 12+ months. $62*
99439 Each additional 20 minutes of clinical time directed by a healthcare professional for chronic care management services. $47*
99491 At least 30 minutes of chronic care management services, delivered by the billing provider, for patients with two or more chronic conditions expected to last 12+ months. $83*
Complex CCM
99487 The first 60 minutes of complex chronic care management services for patients with moderate to complex conditions. $132*
99489 Each additional 20 minutes of complex chronic care management services for patients with moderate to complex conditions. $71*

What are the applicable CPT codes for CCM?

There are several Current Procedural Terminology (CPT) codes that are used to bill for chronic care management (CCM) services in the United States.

  1. 99490- This code is used for at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month.
  2. 99487 – This code is used for the initial assessment and care planning for patients with multiple (two or more) chronic conditions that are expected to last at least 12 months, or until the death of the patient.
  3. 99489 – This code is used for the ongoing care management of patients with multiple (two or more) chronic conditions that are expected to last at least 12 months, or until the death of the patient.
  4. G0506 – This code is used for remote evaluation of recorded video and/or images furnished to the patient/caregiver.
  5. 99458, 99459 – These codes are used for remote evaluation of patient-transmitted recorded video or image by a physician or other qualified healthcare professional via telephone, internet, or e-mail.

It is important to note that the codes and reimbursement for CCM services may vary depending on the payer, so it’s best to check with your local Medicare administrative contractor or your private payer for more information.

Get in touch with our CCM Expert