Chronic Care Management: 5 Steps to Better Outcomes

The number of adults with chronic health conditions has reached 117 million in the U.S. – accounting for 90% of all healthcare expenses. Approximately 42% of Americans have 2+ chronic conditions.  Chronic conditions are putting a serious strain on healthcare and need a multidisciplinary solution, one of them being Chronic Care Management.

The fundamentals of Chronic Care Management are aligned with the goals at the core of value-based care: improve patient outcomes and reduce cost. Coordinated delivery of care through CCM will position physician practices to become a high touch point system that can capture the patients who would otherwise end up in the Emergency Departments or worse admitted. 

Gen By Gen Health’s turn-key CCM solutions manage care prescribed by physicians, reduce staff’s administrative workload, and foster high-touch patient engagement resulting in increased revenue and improved quality metrics.

What is Chronic Care Management (CCM)?

The Medicare Chronic Care Management (CCM) program is a service designed to provide additional support and coordination for Medicare beneficiaries with two or more chronic conditions. It allows eligible healthcare providers to bill Medicare for non-face-to-face care management services offered to these patients.

The program aims to improve the quality of care, enhance patient engagement, and reduce healthcare costs by facilitating ongoing communication between patients and their healthcare team, ensuring adherence to treatment plans, and addressing any emerging health issues promptly. 

Medicare reimburses providers for activities such as care coordination, medication management, remote monitoring, and patient education conducted outside of regular office visits, fostering better health outcomes and patient satisfaction.

5 Universal Steps in Implementing and Running a CCM Practice:(CCM)?

1. Patient Selection

Determine which patients are eligible for the CCM Program

( Patients must have at least two serious chronic conditions expected to last at least 12 months).

Patients should not be enrolled in CCM with another practice or provider.

2. Consent: Verbal or Written

Educate patients about the program structure and benefits and its direct services to them

This can be done verbally, with the use of direct mail flyers and handouts, in-office by a staff nurse, or media such as this animated video if your patient is technologically savvy and can use a phone.

3. Care Plan Development

This is the core of CCM!

A licensed clinical team member develops a care plan for patients that is customized to their chronic illnesses. This includes a myriad of items ranging from administrative action items such as scheduling appointments to wellness goals of reducing blood pressure. 

Goals, interventions, and timeline: these are the 3 numerical values that set the quantitative performance indicators for the care plan.

4. Documentation:

In CCM where ALL services provided are non-face-to-face,  accurate and detailed documentation is the most critical part of the process: one that is subject to scrutiny in case of a Medicare audit. A majority of the work done to achieve results is over a call or in-between text messages. Time spent doing this work is also recorded to submit for billing purposes. Our trusted partners below help us document with precision and integrity. 

OpenPhone: Document the purpose and outcome of the call and time spent. Gen By Gen uses OpenPhone to make secure and encrypted outbound calls. Open Phone features that we like are its call recording and transcribing abilities powered more recently by AI to summarize calls and suggest actionable items.

ChronicCare IQ: Well renowned in the CCM space, this robust software has intelligent time tracking and data analytics capabilities.

5. Billing/Reimbursement

Reimbursements for CCM come using CPT code submission (see our blog about CCM codes). Unlike office visits that bill by way of a fee-for-service model by assigning codes to a diagnosis or complaint, CCM’s code assignment is contingent on time spent managing care.

99490: The most common code used for 20 minutes of care management reimburses $63

99439: Add-on to 99490 for an additional 20 minutes reimburses $47

99487: Also called Complex CCM reimburses $133 for 60 minutes spent managing care that is of moderate to high complexity. 

99489:  Add-on code to 99487 reimburses $70 for an additional 30 minutes

Each of these 5 steps can be customized to fit the needs of a practice. Communication can high-touch low volume to capture all complex CCM or the opposite to have widespread reach. 

In the next blog piece, we will discuss what sets Gen By Gen apart from other service providers in the industry. Or you can book a meeting with our CEO Naaz Malek, PA-C to learn more and get started on your journey to value-based care.

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