The Evolution of Chronic Care Management

May 9, 2022 /

evolution of CCM

In the United States, around 60% of adults have one chronic condition and around 40% have two or more chronic conditions. The treatment and management of chronic conditions make up a significant portion of annual healthcare costs. In fact, the U.S. has some of the highest healthcare costs globally, with total healthcare spending reaching $4.1 trillion in 2020 — more than $12,500 per person. 

Chronic conditions typically last for a lifetime and may not have a cure. People with chronic conditions often need ongoing medical care to manage their symptoms and slow down the progression of the disease. The best way to get in front of these conditions is through preventative care to ensure they do not worsen or cause additional health issues. 

Chronic Care Management (CCM), a program first rolled out in 2015 by the Centers for Medicare and Medicaid Services (CMS), provides care coordination for patients with two or more chronic conditions. CCM programs keep patients and their providers on the same page when it comes to the management and treatment of multiple chronic conditions. The overarching goal of CCM is to improve patient outcomes and reduce costs for patients by extending an extra level of consistent care coordination to enrolled patients.  

 

What Is Chronic Care Management?

CCM is a program offered under Medicare Part B for people who have at least two chronic conditions. The program can be delivered under the supervision of a non-physician provider, such as a physician assistant or nurse practitioner, or a physician provider. It can also be provided under general supervision. The program can offer services beyond office visits that help beneficiaries receive preventive care, follow their care plan, and effectively manage their conditions. Ultimately, the goal is to improve the overall health of the patients.

Providers who bill for CCM get reimbursed by Medicare or Medicare Advantage, depending on the patient’s plan. Medicare pays providers separately for services they administer as part of a CCM program. There are five Current Procedural Terminology (CPT) codes providers can use when billing for CCM:

  • CPT 99490: Code 99490 is used for a 20-minute per month service delivered by clinical staff to coordinate a patient’s care across multiple providers.
  • CPT 99439: Code 99439 is an “add-on” code, meaning it’s used for every additional 20 minutes of staff time spent providing CCM (99490) to a patient under the supervision of an eligible provider.
  • CPT 99487: Code 99487 is for complex CCM, meaning treatment requires relatively complex decision-making. It’s for use when staff delivers a 60-minute service to establish or revise a patient’s comprehensive care plan. 
  • CPT 99489: Code 99489 is for any additional 30 minutes of time staff spend delivering complex CCM under the supervision of an eligible provider, so a full 90 minutes in a calendar month.
  • CPT 99491: Code 99491 is similar to 99490 but for 30 minutes of service delivered by a physician or another eligible provider, such as a physician’s assistant or nurse practitioner instead of 20 minutes per calendar month.

No matter what CPT code is billed, CCM is the coordination of care outside of a patient’s regular office visits. Physicians and eligible providers can choose to provide CCM themselves or arrange for CCM services to be provided by a care management company or external clinical staff.

Chronic Care Management and Medicare

The chance of having at least one chronic condition increases as people get older. Care becomes more complex the more conditions a person has, especially if they see multiple providers to manage and treat their conditions. For example, a person with heart disease and diabetes might see a cardiologist for their heart, an endocrinologist for their diabetes, and a general practitioner for preventive care.

Under a traditional care model, the endocrinologist might not be kept in the loop about a patient’s care from his or her cardiologist. The cardiologist might prescribe medications to the patient that interfere with their diabetes medication or the patient might end up repeating lab work and tests. Coordinating care under a CCM reduces duplication and can help improve outcomes by keeping the entire network of providers on the same page.

Some eligible conditions include:

  • Alzheimer’s disease and other types of dementia
  • Asthma
  • Arthritis
  • Atrial fibrillation
  • Diabetes
  • Depression
  • Heart disease
  • High blood pressure
  • Chronic Obstructive Pulmonary Disease (COPD)

Many other conditions not on the list might also qualify for a CCM. Generally, a patient’s condition needs to last for at least 12 months and put them at risk for decline or death.

 

The History of Chronic Care Management

So far, the history of CCM is brief. Let’s take a look at how Chronic Care Management was created and the changes in CCM throughout the past few years.

2015: The Beginning of CCM

CCM was introduced in 2015 to help people with multiple chronic conditions optimize their health and improve their care. It is a preventative care service that physicians can receive reimbursement for. 

Chronic Care Management requires 20 minutes to be spent monthly on non-face-to-face CCM services. The service can be performed by clinical staff who can either work for the provider’s practice or be an outsourced party under general supervision of the provider. The program requires e 24/7 access to a care team member for enrolled patients.

Before a patient can begin to receive CCM services, they need to have a face-to-face visit with a provider. The face-to-face visit was for patients who were new to the provider or who hadn’t been seen within a year. Examples of initial visits include wellness visits or preventive physical exams. The initiating visit is billed separately from the CCM services.

A key element of CCM is the care plan, which is created after the first CCM conversation. Each month, a patient’s CCM team builds on the care plan. 

The care plan needs to include the following:

  • A list of problems
  • Prognosis and expected outcomes
  • Symptom management
  • Medication management
  • Planned interventions and responsible parties for those interventions
  • Quantifiable treatment goals
  • Description of coordination with agencies and specialists outside of the practice

2017: Introduction of Complex CPT Codes

CMS’s original rule allowing for CCM introduced CPT Code 99490. Two years later, CMS introduced codes for “complex” CCM. Complex means that creating a care plan requires a moderate or extensive amount of medical decision-making.

Providers can bill under CPT 99487 for services that meet the following criteria:

  • The patient has at least two conditions that put them at an increased risk of functional decline, decompensation or death.
  • The conditions are expected to last for at least 12 months or until the patient dies.
  • The provider is establishing or substantially revising the care plan.
  • The revision or establishment of the care plan requires moderate or very complex medical decisions.
  • Clinical staff spend 60 minutes of non-face-to-face time on the plan under the supervision of a physician or another eligible provider monthly.

Code 99487 extended the time clinical staff spent on a CCM plan for patients, recognizing that some care plans require more time and complexity than others.

2020: Response to the COVID-19 Pandemic

The COVID-19 pandemic changed many aspects of health care. In the early days of the pandemic, healthcare spending dropped considerably. It was lower than average as people turned to telehealth and in-person visits did not resume until nearly the end of the year. 

CMS issued an emergency blanket waiver to providers in response to the pandemic. The waiver allowed providers who were previously ineligible to offer telehealth services to provide those services to Medicare patients.

CMS aimed to incentivize telemedicine services during the pandemic by offering financial incentives for telehealth, such as paying physicians the same rate for telehealth as for in-person visits. It also allowed providers to see new patients through telehealth. 

Remote care was clearly an influential change during the pandemic. Similar to telehealth, the popularity of Chronic Care Management grew and the utilization of the program grew as well. More patients were calling in for assistance and questions during such a disconcerting time. Being able to rely on a remote program was crucial.

2021: Bill H.R. 4755

Thirty-five million people in the U.S. have Medicare and at least two chronic conditions. Of those 35 million people, only 684,000 participate in CCM services. In July 2021, the Seniors’ Chronic Care Management Improvement Act of 2021, Bill H.R. 4755, was introduced in Congress. The bill seeks to amend the Social Security Act to remove the patient cost-sharing requirement under Medicare Part B.

When people sign up for Medicare Part B, they pay a monthly premium of at least $170.10. In addition to the premium, Medicare Part B participants have a deductible of $233. After the deductible, they are responsible for 20% of the cost of any services covered by Part B, including CCM.

Bill H.R. 4755 aims to waive the cost-sharing requirements for services billed under CCM codes. The argument for removing the cost-sharing is that it acts as a barrier to care, preventing people who would benefit from a CCM from signing up for the service.

The bill has support from the American Medical Association (AMA), the American College of Physicians, the American Academy of Family Physicians and other medical organizations. 

2022: Relative Value Unit (RVU) Increases

CMS regularly updates the Physician Fee Schedule (PFS), changing payment policies and rates. A RVUs Update Committee (RUC) reviews relative value units regularly and recommends changes if it determines that services are undervalued. In 2021, it recommended changes to the RVUs for CCM. Those changes were accepted by CMS and implemented into the Calendar Year (CY) 2022 Medicare Physician Fee Schedule (PFS) final rule.

Among the changes recommended by the RUC was a 55% increase in the RVU for CCM CPT codes. For example, before the CY 2022 Medicare PFS final rule, the work RVU for CPT Code 99490 was 0.61. The RUC recommended an increase to 1.0, which CMS accepted. 

Medicare uses RVUs to determine how much to reimburse providers. RVUs standardize and compare service volumes across continuums, considering the skills and acuity needed to perform certain services. RVUs essentially reimburse providers based on the relative value, or how challenging a service is to offer. 

By agreeing to increase the RVU for CCM CPT Codes, Medicare agrees that the value provided by CCM services is significant enough for providers to receive a sizable reimbursement. 

Emphasizing Value-Based Care

The goal of value-based care is to improve care quality and patient outcomes. The quality of how a patient receives care greatly affects their health outcomes. Value-based care focuses on patient wellness and prevention to influence positive patient outcomes. 

CCM is a value-based program. Patients who enroll in CCM services tend to have lower rates of hospitalization and fewer visits to the emergency department (ED). They also tend to have more preventive care evaluation and management (E/M) encounters than people who aren’t enrolled in CCM services.

The more providers who offer CCM services and the more incentive there is for patients to participate, such as reducing cost-sharing requirements, the better the health care system will be overall.

 

Challenges of Chronic Care Management

Although CCM has the potential to improve health care and patient outcomes in the U.S. vastly, there are still several challenges that can stand in its way. 

One of those challenges is the cost of care. While Medicare is the federal health insurance program for older adults, it’s not free. The program is divided into multiple parts and each one has its own premiums and deductibles. Medicare Part B, which covers CCM, has a monthly premium, annual deductible and 20% co-insurance requirement

The cost of certain services, including CCM, might be out of reach of Medicare beneficiaries. Ten percent of Medicare beneficiaries spent more than half of their income on health care in 2018. The average person with traditional Medicare, Parts A and B, spent more than $6,000 on premiums and medical services. 

The high cost of care under Medicare can cause many people who would otherwise benefit from CCM to skip it. Uptake of the services has been notably lower than hoped. Eliminating the co-pays connected to Medicare Part B would reduce the cost of care and encourage greater participation. If bill H.R. 4755 becomes law, it would eliminate this obstacle. In the meantime, CCM providers must put a lot of extra effort into strategizing and executing the patient enrollment process.

Another challenge providers face when implementing CCM services on their own is a lack of time and staff. Many providers don’t have the staff available to implement the services or provide 24/7 care and availability to participating patients.

Fortunately, outsourcing CCM servicing allows providers to offer their patients Chronic Care Management without straining their own resources.

About ChartSpan

ChartSpan aims to improve patient health outcomes and reduce patient healthcare spending dramatically. To reach our goals, we strive to deliver solutions to providers that let them engage in patient care while optimizing outcomes. We truly believe that proactive engagement is the key to better outcomes. 

We work to alleviate providers’ workload while increasing their revenues and offering valuable support. When providers partner with us, they get access to the country’s largest and most practiced CCM managed service provider. 

 

Learn More About Our CCM Services Today

CCM services help patients prevent their conditions from worsening while receiving the care and attention they need. CCM plans help prevent patients from slipping through the cracks and minimize medical errors and redundancies.

Contact ChartSpan today to learn more about how our CCM services can benefit your practice and patients. 

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