Medicare Pays for Chronic Care Management

Physicians Stand to Boost Care Quality and Bottom Line But Face Hefty Requirements

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Quality Feature — September 2015

Tex Med. 2015;111(9): 45-50.

By Amy Lynn Sorrel
Associate Editor

Making referrals. Coordinating care among settings. Managing multiple medications. Taking after-hours phone calls. The list goes on of behind-the-scenes activities primary care physicians do to give top-notch care to their chronically ill patients. 

For years, Medicare did not pay for that work, beyond a face-to-face visit. That's changed. 

As of January, the Centers for Medicare & Medicaid Services (CMS) began paying for chronic care management of patients with two or more conditions under its Chronic Care Management (CCM) program. The payment applies to patients in traditional fee-for-service and noncapitated Medicare Advantage plan arrangements.

As with most things Medicare, Texas Medical Association leaders caution the program may require heavy lifting for some practices. Still, physicians generally cheer the move as a long-overdue recognition of all that doctors do to care for patients with complex needs. And they hold hope the new code can deliver a two-for-one deal that can boost physicians' bottom line now and better position practices for the future payment paradigm that places a greater emphasis on quality improvement. 

"It is rigorous. It is lengthy and detailed, and I would not do it this way. But among all the things CMS throws at us — meaningful use, PQRS [Physician Quality Reporting System], and other regulations — this is a breath of fresh air and an acknowledgment of all the hard work most primary care physicians do. And that's a lot of work," says Austin internist Ghassan Salman, MD, a member of TMA's Council on Health Care Quality and chief executive officer of Austin Diagnostic Clinic (ADC). The primary care group is in the process of restructuring to take advantage of the new CCM program.

Practices must do their own math to decide whether the program is viable. But Dr. Salman says it's about more than just money. 

"This is something that is in the best interest of our patients. With the time we spend doing these things, patients will get better, physicians will get better reimbursement, and if done correctly, it will cost the system less money," he said. As Medicare and commercial insurers increasingly turn to alternative payment models that emphasize care management and coordination to keep costs down, Dr. Salman adds: "This may become the way we practice, and the [CCM program] is a step that can help move physicians in the direction of value-based care delivery." 

Billing the 99490 CCM Code

Under the CCM program, physician practices can earn an average $42 per month per eligible patient for non-face-to-face care coordination services. Patients must have at least two chronic conditions that are expected to last at least a year or until the death of the patient, or that create significant health risks, such as hospitalization or a decline in quality of life. 

"If you look at Medicare research, that's when costs start to go up significantly, and CMS is hoping that as groups engage this population more proactively, they will be able to address these issues before they become exceedingly acute and benefit the patient, as well as Medicare, in terms of cost," said David McCormick of Innovista Health Solutions, a partner of TMA's physician services organization, TMA PracticeEdge. (See "Cutting Edge," May 2015 Texas Medicine, pages 26-31.) He is chief information officer and president for the Central Texas market.

With two-thirds of Medicare patients diagnosed with two or more chronic conditions, federal officials say the program "is only one part of a multifaceted CMS initiative to improve Medicare beneficiaries' access to primary care" and help reduce costs. The move builds on CMS' 2013 codes to pay for transitional care management and dovetails with other incentive programs to test and encourage participation in medical homes, accountable care organizations (ACOs), and other alternative payment models. 

To bill the 99490 CCM code, practices must first get patients' consent to participate and develop a comprehensive, patient-centered care plan that is electronically available at all times to all members of the practice team involved in chronic care activities. Experts say physicians can create the care plan during separate office visits or via online questionnaires. 

The program does not require practices to attest to meaningful use, although many elements entail use of a certified electronic health record (EHR) system and a formal care management program to capture, document, track, and share patient information. Among other program elements, practices must be able to offer:  

  • Structured recording of patient health information;
  • 24/7 access to care that gives patients a way to make timely contact with someone in the practice who has access to the patient's care plan;
  • Facilitation of care transitions between settings, including referrals, and follow-up after hospital discharges and emergency visits;
  • Prescription management and reconciliation; and 
  • Care coordination in and outside the practice, for example, with specialists, and home and community-based services.  

The code allows practices to bill for documented non-face-to-face care management and coordination activities that consume at least 20 minutes of staff time per month, either all at once or incrementally. Other billing requirements weave a web of rules practices must follow closely to get paid:   

  • Practices can bill the code only once per calendar month;
  • Only one clinician at a time can provide and bill for CCM services; and
  • Practices cannot bill for certain other codes during the same month as they bill for CCM services: transitional care management (TCM) and certain services for home health, hospice, and end-stage renal disease.  

Medicare relaxed certain "incident to" billing rules that normally would require physicians to be on site to directly supervise chronic care services provided by other licensed clinical staff, which can include nurse practitioners, physician assistants, and medical assistants. 

But Medicare still requires some cost-sharing from patients, who must pay a monthly copay of about $8, or 20 percent. TMA officials warn routinely waiving patient copays is illegal under state law and could invite a Medicare investigation. (For more details, read this TMA Practice E-Tip.) 

Calculated Risk

Financial incentives in the CCM program can be substantial. (See "Running the Numbers.") Still, TMA leaders acknowledge it may require an equally significant investment and commitment from practices to adapt workflow or create the infrastructure needed to reap the rewards. 

For instance, Mr. McCormick says those already on the path to becoming a medical home or joining an ACO — whose requirements generally overlap — may have an easier time. "Practices are going to have to evaluate where they are on the spectrum of providing value-based care, and the question is: Can we take this on by ourselves, or do we need help?" 

On the other hand, even as Medicare pursues an overall value-based care strategy, Dr. Salman highlights the CCM program is available to all primary care practices, regardless of size, and doesn't require medical home recognition or participation in an ACO.

"Primary care physicians are best positioned to deliver this service, and size doesn't matter. What matters is, do you have the right population of patients with two or more chronic medical problems? The more you have, the more it makes sense," he said. "The challenge is crystallizing these haphazard and irregular activities into a streamlined process that can be documented to justify it to CMS." 

The financial rewards likely would offset the cost of an EHR upgrade or new personnel, he adds. Even for a larger system like ADC, "we are investing a significant amount of money to get this to take off. But we estimate that if 6 percent of our patients have two or more medical problems, the system will generate enough money to cover the cost. Financially, it may be nil to the clinic, but it will be positive to the physician and the patient, and that's still a very reasonable business case." 

Boon or Bust?

Within a few months of implementing the CCM program, Southwest Provider Partners ACO has seen tangible improvements and efficiencies in care that also helped further the group's goal of generating additional shared savings for participating physicians, says the ACO's Director of Quality Improvement Gurneet Kohli, MD. "When I heard about this program, I was ecstatic. At the end of the day, doctors felt like they were getting the short end of the stick. This is definitely a step in the right direction for CMS to see the value in this work."

The Austin internist says the hard part for physicians was not identifying eligible patients, enrolling them, and creating a clinical care plan; it is really tracking the time spent on non-face-to-face interventions and ensuring the necessary monthly follow-up. For that, they enlisted the ACO's care coordinators and Innovista's population health management tool. 

Regular communication with patients has since helped pinpoint important health and social issues that normally don't come up in a face-to-face visit.

Until a nurse called, one of Dr. Kohli's patients never mentioned her medication was causing her diarrhea because she didn't want to bother the doctor. The practice adjusted the dose. Other times, he had no idea why patients didn't show up for appointments until care coordinators discovered they didn't have transportation because a family member got stuck at work.

"These are such small things for us, but such big things for the patient. And we are moving beyond just measuring blood sugar or cholesterol levels to things that quality measures don't measure," Dr. Kohli said. 

When it came to getting patients on board, "most said it's about time [Medicare] did this," he added. With two or more chronic conditions, most patients easily meet their annual Medicare deductible, and their secondary insurance kicks in to cover the $8 copay. 

"I had a wife who enrolled, but her husband was more 'wait-and see.' Two weeks later, I got a message he was so happy with the service provided to his wife, he wanted to join, too," Dr. Kohli said. "We have higher patient satisfaction and retention, and this could be a competitive selling point for a practice. The more positive results I got, the more strongly I could advocate for the next batch of patients to enroll." 

Convincing patients of the program's benefits was not so easy for Athens family physician Douglas W. Curran, MD. The TMA Board of Trustees chair was "very optimistic" when he heard about the program, but what he described as "busy-work, not patient care work," quickly turned that optimism into "overwhelming burden." 

His 14-physician group already has an EHR system but found it lacked the capabilities to fulfill the CCM program's documentation requirements. 

"We do 20 to 40 medication refills a day. We're keeping patients out of the hospital, and we know the ones who follow the rules and the ones who don't. We're doing the work. We're just not getting paid for it. And this program is just creating more work," Dr. Curran said. 

He also found himself spending too much time explaining to patients why they had an extra copay when they weren't visiting the office. "We're a small town, and I know my patients, and they know me. And they'd get really unhappy with me. It is a real dilemma." 

Nor could Dr. Curran bill for TCM, which pays more. "Most of these patients are sick enough that they are in and out of the hospital. And in a small town, we are the hospitalists for our small hospital." 

TMA officials say most practice management systems do a good job of letting physicians know which services they bill for each month, but some coordination may be necessary. When it comes to crossover with CCM services, Medicare has indicated it will pay for the code billed first by a physician practice in a given month. For example, if practices bill TCM first and CCM later the same month, Medicare will deny the latter code, or vice-versa.

Now with a better grasp on the scope of requirements, "we're going to give it another go because we know we're leaving money on the table," Dr. Curran said. "There's no doubt if you empower primary care physicians like me to take chronic care patients, there's a world of change in terms of outcomes and cost of care. It's money I'd love to have if we can just figure out how to capture and document all the things they want us to document." 

Added Value

Any investments practices make now also will work to physicians' advantage in the near future, as many components of the CCM program overlap with requirements physicians face under Medicare's evolving quality reporting programs, says TMA Director for Clinical Advocacy Angelica Ybarra

Currently, of the 250 PQRS measures physicians can choose, roughly 40 fall under the category of care coordination. Practices also can use CCM activities to meet patient satisfaction measures.

Under the new Merit-Based Incentive Payment System (MIPS) established with the elimination of the Medicare Sustainable Growth Rate (SGR) formula, physicians who demonstrate care coordination, enhanced access to care, and patient engagement, for example — all components of the CCM program — can use those activities to meet the MIPS Clinical Practice Improvement requirements. (See "SGR Is Gone. Now What?")

The Medicare and CHIP Reauthorization Act also calls on CMS to report to Congress in 2017 specifically on the use of CCM services, identifying barriers and making recommendations for broader adoption. 

Dr. Salman warns, too, that if physicians don't use the new CCM program, CMS could take it away.

Meanwhile, Mr. McCormick notes that private insurers are adopting similar programs, and physicians can use Medicare's playbook to position themselves for commercial value-based contracts, which tend to pay more. "It's important for all payers to realize that physicians are the most efficient means to engage patients and promote the behavior change we all want to see." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


Get CCM Help From TMA

While many physician practices are likely to be interested in the enhanced revenue and patient care improvements from the Chronic Care Management (CCM) program, they might lack the operational efficiencies, technological infrastructure, and ability to handle the additional workload. Practices can find help through TMA Practice Consulting and TMA PracticeEdge. 

To find more information about implementing a CCM program in your practice, sign up for one of the TMA Medicare seminars in November and December 2015 or the new webinar series coming this fall. 

TMA PracticeEdge also is developing a turnkey solution, including patient eligibility identification, structured data recording, and care management services. 

Learn more about TMA Practice Consulting and TMA PracticeEdge


Running the Numbers

150 patients with 2 or more chronic illnesses x $42 monthly CCM payment* x 12 months = $75,600

*Average, subject to regional variation

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CCM Resources

TMA Chronic Care Management Resource Center

TMA's upcoming Chronic Care Management webinar series
Call TMA Practice Consulting at (800) 523-8776


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