Complete Guide to Chronic Care Management

Chronic Care Management is in the Full Glare of Public Attention

Every year, millions of Americans are affected by chronic diseases, such as diabetes, heart disease, cancer, arthritis, asthma, and other chronic care conditions. The disorders also cost billions of dollars yearly in medical expenses, including long-term treatment and monitoring.

By definition, chronic diseases are the ones that last for at least a year. The Centers for Disease Control and Prevention (CDC) estimates that over 80 million adults in the United States have chronic conditions.

The diseases can cause serious complications, such as amputations, blindness, kidney failure, and even death if left untreated. Fortunately, there are ways to prevent and control chronic diseases with chronic care management services (CCM). 

Chronic disease management is a contemporary approach to managing chronic disease patients. It helps doctors and other healthcare providers manage their patients’ health.

In this guide, we will touch upon the following points on chronic disease prevention:

  • Section 1: A Gist of Chronic Care Management
  • Section 2: Developing a Successful Chronic Disease Prevention Plan
  • Section 3: Chronic Disease Management Coding and Billing
  • The importance of chronic care management today
Section 1

A Gist of Chronic Care Management

A Gist Of Chronic Care Management - 360 HealthTek

What is Chronic Care Management?

Chronic care management encompasses the care medical professionals provide for their chronic disease patients. A disease is chronic if it lasts for at least a year, requires ongoing medical treatment, or hinders daily activities. The disease includes both medical and psychological conditions, such as diabetes and depression.

In the United States, chronic disease management definition is the chronic care services provided to Medicare patients with various chronic diseases. Besides face-to-face consultations, the services include chronic disease-related communication and therapy.

Chronic disease prevention requires a comprehensive treatment approach that includes:

  • A paper outlining the patient’s chronic conditions
  • Personal particulars
  • Goals
  • Healthcare vendors
  • Medications
  • Additional required numbers of treatment 

The comprehensive chronic disease management plan outlines the therapy and coordination details for the patients.

Medicare’s CCM coverage has recently been increased for patients with two or more chronic conditions likely to persist for at least a year.

What is a Chronic Condition Eligible for the CCM?

To qualify for Medicaid’s CCM Program, patients must have at least two chronic diseases. Below is a list of some of the most significant qualifying chronic illnesses.

To qualify as a chronic disease patient covered by the virtual chronic care management program, a patient’s illness must:

  • Be a condition that is expected to continue for at least one year or until their death.
  • Be a condition that significantly increases the risk of mortality, functional decline, or exacerbation/decompensation for the patient.

 However, the following are widespread examples:

  • Alzheimer’s disease
  • Arthritis
  • Asthma
  • Cancer
  • Dementia
  • Depression
  • Diabetes
  • cardiac disease
  • Hyperlipidemia
  • Hypertension
  • HIV/AIDS
  • Parkinson’s illness

CMS Extensively Supports CCM 

A detailed analysis of the 2022 Medicare Physician Fee Schedule proposed and final rule prove that CMS continues to promote chronic disease management. The agency’s readiness shows the change to adopt the RVS Update Committee’s (RUC) proposed up-to-date values for ten CCM family codes. While not atypical for a regulation, the CMS seldom used language as the justification.

Physician fee schedule regulations are thoroughly examined and scrutinized by several committees. For that reason, many options are available to eliminate that language. Due to its inclusion in the proposal, it is fair to conclude that CMS’s recommendation for a considerable raise in the program’s payment implies Chronic Care Management has gained momentum as a CCM plan.

The latest payment amendment mirrored the original proposal and considerably raised compensation for the CPT codes related to chronic disease prevention.

The Ever-Growing Popularity of CCM

In recent years, the CMS has shown its support for chronic disease management in several ways, including the rise in chronic care management reimbursement. In the 2022 proposed rule, CMS supported chronic disease prevention in various forms, particularly the 2014 decision to approve a specific HCPCS code for CCM, HCPCS GXXX1, and the 2015 implementation of separate billing for chronic care management solutions according to CPT 99490.

The following are the ways CMS has expanded its support for chronic disease management payments throughout the years:

  • CMS introduced a new Chronic Care Management CPT code 99491 according to the 2019 Physician Fee Schedule final rule. That code reimburses doctors each month for 30 minutes of CCM treatment.
  • CMS created payment for an add-on code to CPT code 99490 by introducing HCPCS code G2058 in the 2020 final rule. CMS also launched two new HCPCS G codes: G2064 and G2065.
  • CMS brought a replacement code for HCPCS code G2058 in the 2021 final rule: CPT 99439.

In 2022, the CMS expanded the reimbursement for the five new CPT codes listed below: 

  1. CPT 99437
  2. CPT 99424 
  3. CPT 99425 
  4. CPT 99426 
  5. CPT 99427 

With the final rule securing the increase in compensation, Chronic Care Management is now among the most profitable Medicare chronic disease management programs. To better understand how practitioners use CCM, let’s examine one of the most prevalent co-occurring chronic conditions that make CCM a viable option for many patients.

Hypertension and CCM

To better grasp the way chronic disease management benefits patients, providers, and our healthcare system, let’s examine how it applies to one of the most prevalent chronic conditions.

  • Hypertension takes place once blood pressure consistently stays excessive force pushes on the sheer walls of blood vessels. In recent years, a more significant number of Americans (over 100 million) suffer from silent chronic high blood pressure, leading to major secondary health problems, such as heart attacks, heart failure, and strokes.
  • Approximately a quarter of Americans struggling with hypertension have the illness under control. Because of the absence of apparent symptoms, patients take hypertension for granted and get it treated with less gravity. Practitioners have advised the patients for years to correct this mindset and track hypertension symptoms at home.
  • Self-monitoring is effective. However, requiring patients to record readings and take prescribed medications does not always offer the direct supervision or support many individuals need to maintain hypertension monitoring and control. Practitioners and their care teams spent many hours guiding their patients between routine office visits; until recently, most payers, including Medicare, did not reimburse the care providers for the time they spent on the patients. That is where the CCM for hypertension plays a vital role.
  • CCM program offers a more efficient mechanism for practitioners to give comprehensive, high-quality treatment to patients while earning fair remuneration. In 2015, Medicare started compensating practitioners for chronic care management for Medicare patients with two or more diseases, most of whom had a chronic hypertension problem. Medicare has just added the latest CPT codes for complex chronic and principal care management.

Patients may have significantly improved outcomes through early diagnosis and treatment of hypertension with CCM. As a result, we can fairly reimburse clinicians for their effort in helping hypertensive patients. With many advantages associated with CCM software, one may predict its broad acceptance, and this can only be possible when practitioners acknowledge the benefits of the chronic care management program.

Section 2

Developing a Successful Chronic Disease Prevention Plan

Developing A Successful Chronic Disease Prevention Plan - 360 HealthTek

The key to chronic disease prevention success is an organization’s commitment to starting a program and laying its structure, involving designing processes, educating people, and finding the program that will help put the program into action. But all this effort will be of no purpose if patients fail to understand the program, decline to take part in the CCM program, or leave because of not seeing any worth. Patient education is crucial for successfully enrolling patients in the CCM system.

Before enrolling patients in CCM, ensure that you discuss the expected costs with the patients associated with their participation. Practitioners are often responsible for educating patients on the overall benefit of a chronic disease prevention program. 

Justifying Patients’ Costs for CCM

It is essential to understand the context of financial terms. Concerns about personal expenses, for instance, must be evaluated and solved with a better knowledge of chronic care management’s total worth. Patients may be more receptive to enrollment and involvement if they realize they would save money — possibly a considerable amount — in the long term. A few organizations provide financial support programs for those patients who need the facility the most to make the program accessible to more patients.

To get patient support for chronic disease prevention programs, it is necessary to show them its potential benefits. Here are five examples you may share with them.

  • Spending Less on Hospitalization — If chronic disease management helps avoid hospitalization even once, the cost will be readily justifiable. Consumer Health Ratings estimate that the average hospitalization expense for all diseases in 2021 will exceed $13,000, excluding physician costs.
  • Effective Medicines and Symptoms Management — With premier CCM, providers may determine what types of medication are helpful and can remove potentially hazardous or superfluous substances. Symptoms are better managed with carefully prescribed drugs and efficient medication administration.
  • Improved Access to Care Providers and Other Resources — By eliminating the tedious traveling for office visits, CCM ensures the timely delivery of time-sensitive information to the care providers. In addition, CCM helps directly connect to the patient’s care team, guaranteeing that once a care-related concern or query occurs, the patient will get assistance and answers from a qualified practitioner.
  • Healthy Lifestyle — A CCM system brings care to the patient by enabling them to access telehealth services through a user-friendly chronic care management platform that brings up-to-date treatment and vital data, including remote patient monitoring. The coordination helps healthcare teams make better-informed decisions, motivates the patient to be more responsible, and reduces the frequency of office visits and travel time. These therapeutic advancements reduce the emergency care requirements and the relevant heavy expenses.
  • Better Coordinated Care — The University of New Hampshire reports that duplication of laboratories and imaging loses about $20 billion annually in healthcare. Improving care coordination diminishes the possibility of the duplication.

Creating a Brochure for CCM Patients

To improve patient education, practitioners may provide instructional booklets during in-person consultations. Research shows they bring several advantages. Though some patients opt for online research, most depend on printed resources such as pamphlets. A beautifully designed brochure may also be printed and distributed online.

Let’s analyze some essential components of a quality brochure for chronic disease prevention.

  • Add a Definition of CCM — Define chronic disease management in simple language.
  • Explain CCM Eligibility — Informing patients of their possible eligibility may encourage them to enquire about their involvement in a CCM program and encourage them to comply.
  • Provide Information on Time Commitment — It is essential to explain how CCM can make patients’ lives more comfortable by minimizing office visits and providing them with better access to telehealth solutions.
  • Explain the Cost of CCM — It is prudent to inform patients in the brochure that Medicare often reimburses CCM and incurs low out-of-pocket expenses. Motivate them to speak with an organization’s representative who can provide a detailed, customized breakdown of expected costs.
  • Who Takes Part — Patients must comprehend the idea and importance of a CCM organization that will assist them with the chronic disease program. Describe how a coordinated care team support network will enable patients to experience effective care whenever required.
  • Healthcare Objectives of CCM — Among the most compelling reasons for patients to engage in a CCM system is its ability to help them remain healthy and progress toward achieving their healthcare goals. Use precise and unambiguous language to assist people in drawing similarities between their health and well-being and CCM solutions. Consider if the patient group needs information in several languages.
  • Taking the first steps toward Chronic Disease Management – Assist patients in overcoming the barrier of getting enrolled in chronic disease treatment by clearly mentioning the measures they will be required to perform. It is helpful to expect queries from them, for instance, “Am I required to discuss with my primary care provider (PCP)?” and “Should I talk with an on-site patient care advocate or program coordinator, like a nurse case manager?”

When writing the material for your brochure, make the information easy to understand and follow. The optimal approach for patients and your program is to give them enough details to satisfy their curiosity and start a dialogue with you.

Evaluating CCM Organizations

Not all CCM firms are the same; some provide more extensive services and employ more competent personnel than that of others. There are several considerations to remember while selecting a chronic disease prevention partner. Take into account the following in your business assessment and evaluation:

How Effective is the Business’s Solution?

A chronic disease management firm may provide your healthcare organization with various options. Some organizations offer care management platforms that integrate into your organization’s EHR. In addition, some organizations allow access to a team that may extend your practice’s employees. A CCM provider may also offer a mix of software and services to boost your organization’s productivity and reduce its workload. Ideally, a CCM partner’s offerings would be tailored to your organization’s specialization, enabling a chronic illness management solution that caters to your particular issues.

After confirming that the organization provides software and care management services, analyze each area separately. Consider the following while analyzing the software program, such as ours:

Does Your CCM Software Connect Easily with the Clients’ EHR? 

Yes, we will incorporate the Chronic Care Management software into your practice’s electronic health record instead of functioning as a separate tool. A patient’s data and interaction summaries can be accessed in the patient’s record with the seamless integration.

Would It Provide Chronic Disease Care Modules? 

The software for chronic care management provides disease-specific care modules to guide monthly talks. A competent CCM software vendor should have developed care modules for the most prevalent ailments.

Does It Make It Simple to Record Time? 

Time tracking is essential for correct invoicing but may also be vital for clinical operations. Ideal chronic disease management software should enable your entire team to log time without interfering with other operations.

Does It Simplify Billing at the End of the Month? 

If you want your team to spend less time on end-of-month invoicing, search for chronic disease prevention software that automatically calculates costs based on recorded activity. Billing teams may save many hours monthly with automatic charges computation and submission to their EHR.

Does It Increase Productivity? 

A CCM program will save your team time while enhancing the quality of patient care.

Besides reviewing the software, evaluate the vendor’s chronic disease prevention service offerings if you plan to outsource care management. 

How Does the CMS reimbursement eligibility work?

To be eligible for CMS reimbursement, a patient must be examined by certified health professionals. That implies an accredited nursing aide (CNA) has the qualifications to operate as a care manager. Other suppliers are more selective about their hiring practices. A vendor may need a care manager to be a medical assistant (MA) or a licensed practical nurse (LPN).

Another item to evaluate is a chronic disease management provider’s recruiting procedure for care managers. Determine the extent of the hiring procedure. Some suppliers, for instance, have a lengthy interview procedure and demand clinical exams to confirm a candidate’s skills and aptitude for the position.

Is the Technology User-Friendly?

Due to the busy nature of your practice, you do not want your staff to struggle with the latest CCM program that does not seamlessly integrate into your existing EHR.

When picking a provider, it is essential to assess the technology’s usability. 

Does the Installation Process Seem Complicated or User-Friendly? 

If the firm provides training, how often does it conduct training sessions? What happens if you recruit new staff members that need software training?

Some chronic illness symptom management software firms begin the implementation process by collaborating with a healthcare institution to establish objectives and milestones. The firm should provide the most efficient, simplified, and straightforward chronic disease management workflow that fully comprehends your organization’s CCM solution requirements and Medicare’s criteria.

Once your firm successfully implements the program, the chronic disease prevention solution provider must offer assistance. The CCM partner may suggest essential amendments to enhance the software’s usability.

How Does EHR Vendor Integration Work?

A chronic disease prevention solution should operate with your organization’s EHR, not against it. The software should ideally become an extension of the EHR, immediately integrating data into the patient’s record and transmitting all essential papers to your current system. During an interview or demonstration, find out who the EHR prospective vendors work with and how the integration process works.

Consider whether your business intends to use behavioral health integration or remote patient monitoring system. Take some suitable initiatives if you’re currently using an EHR-integrated system.

What are the Overhead Expenses?

By outsourcing care management and using chronic disease prevention software, your healthcare institution may save money once it eliminates the need to engage a full-time care manager. In addition, outsourcing care will help you expand your care management program, boosting income from the care program if you have limited staff. 

Software platforms and chronic disease management services are not free; some can be more expensive than others due to hidden costs. The supplier may charge different prices for just software and the complete service. Some organizations provide a hybrid pricing chronic disease management model that enables your company to expand care services based on its needs and growth. When you initially deploy a chronic disease prevention solution, it’s possible that you need software. As the number of participants in your program increases, you may find that outsourcing care management will enable you to treat more patients by upgrading your software Medicare chronic disease management plan.

What Are Security Measures Available?

Use software that conforms to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Pick a Health Information Technology from an Economic and Clinical Health Act (HITECH)-certified vendor to help maintain patient confidentiality and security. When hiring suppliers, please inquire about the methods they use to preserve and maintain the safety of patient data.

Section 3

Chronic Disease Management Coding and Billing

Chronic Disease Management Coding And Billing - 360 HealthTek

In recent years, the federal government has increasingly supported care management initiatives. Meanwhile, it is also reviewing compensation for chronic disease management more rigorously. It is essential to follow the regulations of CCM billing codes consistently and correctly. Anticipate additional audits to explore the reasons for overpayments related to improper service billing.

Coding for CPT 99490 & the various Other CCM Codes

Let’s examine the most prevalent chronic care management CPT codes for CCM.

CPT 99439 and CPT 99437

CPT 99437 and CPT 99439 are two chronic disease prevention add-on codes. In 2021, CPT 99439 superseded the HCPCS code G2058, while the 2022 Medicare Physician fee schedule final rule introduced CPT 99437. 

CPT 99439: CCM services, each extra 20 minutes of clinical staff time per calendar month led by a physician or other qualified healthcare provider.

When to Submit Form CPT 99439

In the 2020 physician fee schedule final rule, the CMS established payment for HCPCS code G2058. One year later, the CMS opted to supersede G2058 with CPT 99439. We may submit this code only twice a month with CPT 99490 to account for the extra care that surpassed the allotted 20-minute time.

CPT 99437 CCM services for each extra 30 minutes per calendar month provided by a physician or other competent health care provider.

When to Submit Form CPT 99437

This code should only charge for time beyond the first 30 minutes spent delivering services under CPT 99491.

Additional Popular Care Management Codes

Besides those chronic disease prevention codes, businesses that have created a comprehensive care management system charge chronic disease management for additional services. Remote physiological monitoring, behavioral health integration (BHI) care management services, and, less commonly, primary care management are three forms of telehealth services (PCM).

Take away

Chronic disease management is looking forward to a change, and the time is now for a more comprehensive and integrated approach to care. This shift could lead to better patient outcomes, increased efficiency, and reduced costs. The change has many potential benefits, but it will require a concerted effort from patients and caregivers. The time is now for a shift in care strategy, and there is no turning back.