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Medicare Chronic Care Management

Living with a chronic illness can dramatically impact a person’s quality of life, and there are an estimated four in ten people living with multiple of these conditions in the United States. Luckily, there are methods of chronic care management (CCM) that help make long-term illness care more manageable. Some of this help can include regular check-ins from healthcare providers, extra support in understanding medications, and assistance scheduling needed doctors’ visits.

There is ample evidence that CCM not only improves a patient’s quality of life, but also reduces the number of emergency room visits and repeat hospital stays for chronic illness. This can decrease the cost of healthcare related to these chronic illnesses substantially. Because of the better health outcomes and decreased cost, Medicare offers chronic care management reimbursement for the cost of CCM services. 

In this article, we’ll take a closer look at:

  • How chronic care management is defined by Medicare
  • Typical conditions that commonly qualify
  • The components of the chronic care model that Medicare coverage supports
  • Common billing and coverage questions
  • How healthcare facilities can implement or improve their own CCM programs

What Is Medicare Chronic Care Management?

Medicare covers the cost of CCM for most qualifying patients because it is a proven support that leads to better health outcomes and reduced overall medical costs. The purpose of chronic care management in general is to provide patients with a coordinated medical care plan that encompasses all health issues, medications, healthcare providers, and community services used. 

For Medicare patients specifically, Medicare Part B provides CCM coverage for patients with two or more chronic health conditions that will last at least one year. These could include things like diabetes, heart disease, lung disease, asthma, or arthritis. This coverage will include services provided by a doctor or medical provider to help a patient navigate the complexities of living with multiple chronic illnesses. 

To qualify for Medicare coverage, these services need to include:

  • A care plan developed by a healthcare coordinator
  • A minimum of 20 minutes a month of care support
  • More coordination between your doctors, therapists, pharmacies, and other medical staff
  • Phone check-ins between regularly scheduled appointments
  • Access to 24/7 nurseline support for any urgent medical changes

This support is different from the care coordination benefit rendered after a hospital stay. There might be a monthly fee for this CCM service, and the cost-sharing, deductibles, and copayments/coinsurance amounts will differ by patient.

Because CCM services require a significant amount of staff time and resources, healthcare providers often struggle to meet these needs for their patients. Appropriate coding and billing for Medicare reimbursement for these services can be an additional pain point for providers. A comprehensive CCM platform like TimeDoc can help automate care planning, simplify Medicare coding, and improve staff efficiency.

Is Chronic Care Management Only for Medicare Patients?

CCM is an evidence-based practice that improves health outcomes for anyone with chronic health conditions, and isn’t limited to only Medicare patients. Other insurance providers will reimburse CCM services in different ways. However, this article focuses on Medicare specific details.

What Conditions Qualify for Chronic Care Management?

A medical condition which will last a year or longer that causes significant harm or risk of death qualifies for CCM. A patient with two or more of these chronic care conditions qualifies for Medicare CCM reimbursement. 

There are many conditions that fit this description, but the most common include:

  • Cardiovascular Disease
  • Diabetes
  • Chronic Respiratory Disease
  • Cancer
  • Alzheimer’s Disease
  • Chronic Kidney Disease
  • Osteoporosis
  • Arthritis

What Are the Six Components of the Chronic Care Model?

One of the reasons CCM is supported by Medicare is because of the ample evidence that this model significantly improves patient outcomes. The model for chronic care management itself has been developed over the last several decades. This model takes a broad view of CCM management, and considers all the elements that influence a patient’s ability to manage their condition, including:

  1. The Community
  2. The Health System
  3. Self-Managed Support
  4. Delivery System Design
  5. Decision Support
  6. Clinical Information Systems

Let’s take a closer look at how each of these components can improve patient health and reduce overall healthcare costs.

The Community

The communities where patients live have a large effect on their day-to-day lives, and influence their health outcomes. Community resources like libraries, schools, non-profits, and faith-based organizations can all provide support to people with chronic health conditions. All these community groups can:

  • Fill gaps in the care patients need, like regular check-ins and transportation to appointments
  • Keep patients engaged and mentally stimulated in daily life
  • Promote policies that improve health outcomes

The Health System

The overall health system includes all the organizations involved in providing healthcare to a patient with chronic health conditions, including hospital or doctor’s office visits, physical therapy, and in-home nursing care. These organizations can:

  • Work to consistently improve systems with patient quality of life as a top priority
  • Give financial incentives to providers based on the quality of care they provide
  • Facilitate coordination between the multiple care providers needed for the treatment of chronic illnesses

Self-Management Support

Even with good community and health system support, a patient managing chronic illness needs the tools to be able to access this support. Patients that are empowered to understand and direct their care will have better outcomes as they are able to manage their own health more effectively. Some of the tools needed to prepare patients for this self-management include:

  • Encouragement to create goals and make a plan for managing their health between healthcare visits
  • Physical tools and training on how to use them for self health monitoring, like blood pressure cuffs or blood sugar testing equipment
  • Access to information on what community and health services are available and how to access them. This could include things like phone numbers for nurse check-ins, dates and times for support groups, and information about how to schedule transportation assistance for medical appointments. 

Delivery System Design

Patients with multiple chronic conditions often struggle to keep track of all their needed healthcare appointments, medications, care providers, and lifestyle recommendations. The delivery system needs to help patients manage these complex elements so patients are able to get the full benefit from their care. A CCM platform, like TimeDoc, that automates care planning can help care providers implement a delivery system that serves patients best.

Decision Support

Healthcare staff need to be kept up-to-date on current evidence-based best practices for chronic condition management. This means the healthcare system needs to provide ongoing training and give clinicians enough time and resources to carry them out. This way patients are provided with the best information available and educated appropriately on how to best manage their illnesses.

Clinical Information Systems

Helping patients manage chronic medical conditions takes medical staff, resources, and time to do well. There is a lot of information to keep track of; everything from patient medical histories, to new knowledge on the best treatments for diseases. Organizing all this data so it’s easily accessible is the role of clinical information systems. These systems also need to:

  • Remind healthcare staff, care coordinators, and patients of recommended appointments and check ins to be scheduled
  • Identify patients in need of chronic care management or preventative care to facilitate proactive treatment
  • Review staff and facility performance to improve care and support

A comprehensive CCM platform, like TimeDoc, can significantly reduce the amount of staff time and resources needed to coordinate these information systems.

Is Care Management Covered by Medicare?

Yes, if a patient meets the criteria for CCM, and it is provided according to CMS requirements, this service is covered in part by Medicare Part B. Medicare Part B does have a monthly premium that will also be paid by the patient. According to the Centers for Medicare & Medicaid Services (CMS) “the standard monthly premium for Medicare Part B enrollees will be $164.90 for 2023”. This Part B coverage also includes services like “physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A”.

How Much Does Medicare Pay for Chronic Care Management?

For most patients who opt in to Medicare Part B and pay the monthly premium, Medicare will pay for 80% of the cost of the service, meaning the remaining 20% is paid out-of-pocket by the patient. So if a healthcare provider charges $162 for one hour of clinical staff time for a patient’s CCM, the patient would pay $32 (20%) and Medicare would reimburse the provider $130 (80%).

How Much Does CCM Reimburse Per Patient?

The exact amount of reimbursement Medicare pays to care providers depends on a variety of factors, changes regularly, and is laid out in the CMS physicians fee schedule. Solely for illustrative purposes, the national average for CCM reimbursement in 2023 is as follows:

  • $61: CCM clinical staff first 20 minutes
  • $83: CCM physician or nurse practitioner first 30 minutes
  • $130: CCCM (complex chronic care management) clinical staff first 60 minutes

This is the amount that Medicare will pay to care providers, not the whole cost of service or the out-of-pocket patient cost.

How Often Can CCM Be Billed?

Chronic care management billing can be submitted to Medicare monthly. Only one care provider is eligible to bill Medicare for CCM care per patient, and this patient must have signed a consent form for the service beforehand. The minimum of twenty minutes of required monthly clinical staff care can only be billed once per month, with additional time being coded and reimbursed separately.

What Are the CMS Codes for Chronic Care Management?

CMS uses five CPT (current procedural terminology) codes when billing Medicare for a patient’s CCM. These chronic care management CPT codes are as follows:

  1. 99490: first 20 minutes of clinical staff time for CCM
  2. 99439: each additional 20 minutes of clinical staff time for CCM
  3. 99487: 60 minutes of clinical staff time to create or revise a full care plan for complex CCM
  4. 99489: each additional 30 minutes of clinical staff time for complex CCM
  5. 99491: 30 minutes or more of physician staff time for CCM

For more information on practitioner billing of CCM to Medicare, see this FAQ guide from CMS.

Who Can Make Chronic Care Management Calls?

CCM as covered by Medicare is not a face-to-face service, meaning a staff member will be making phone or video calls to patients. This care must be overseen by a supervising healthcare provider, like a physician, advanced practice registered nurse, or physician’s assistant. The Centers for Disease Control provides a chronic care management call script that gives staff guidance on best practices for having the most impactful conversations.

However, the actual calls themselves can be made by any care coordinator with appropriate chronic care management training. This can include internal staff from the patient’s primary care provider, or it may be done by an external company. In either case, a CCM platform facilitates these calls being made more effectively–by making planning and carrying out calls easier with appropriate technology, or by outsourcing the calls all together. TimeDoc is a platform specifically designed to make CCM programs easier to execute.

TimeDoc: We Can Help with Your Chronic Care Management Program

We at TimeDoc know how important it is for your healthcare practice to provide the best care to your patients. We also know how much time and resources are required to adequately support a chronic care management program that scales with expanding patient numbers. That’s why we created a CCM platform that:

  • Automates care planning
  • Maintains compliance with Medicare
  • Makes documenting care coordinator time easy
  • Increases staff efficiency
  • Reduces time spent on Medicare billing
  • Improves ROI on CCM programs

Get in touch today to make Medicare chronic care management easier tomorrow.