Chronic Care Management

Step-By-Step Guide for Billing Chronic Care Managment Services.

Two-thirds of all Medicare dollars are spent on treating patients with a chronic disease. This figure is alarming and increasing. A new initiative by the Centers for Medicare and Medicaid Services is looking to curb this trend. They have decided to focus their efforts on prevention with the hopes that this will lower the dollars spent on treatment down the line.

As of January 1st, 2015, providers that bill Medicare have the ability to get reimbursed for providing Chronic Care Management services to their patients. Assuming a physician has a population of roughly 500 Medicare patients, the annual reimbursement could exceed $100,000. Qualifying for this payment will require 20 minutes of non-face to face time helping a patient manage their chronic condition.

Am I eligible to bill for CCM services?
  • You must be a Medicare provider.
  • You must be a Physician, advanced practice registered nurse, physician assistant, clinical nurse specialist, or a certified nurse midwife. There is no limitation based on specialty.
  • You must be the only practitioner billing for CCM services for the patient.
  • You must be able to meet these 5 capability requirements:
    1. Use a certified EHR for specified purposes
    2. Maintain an electronic care plan
    3. Ensure patient access to care
    4. Facilitate transitions of care
    5. Coordinate care
Which patients are eligible to receive these services?
  • Your patient is eligible if he or she has been diagnosed with 2 or more chronic conditions expected to persist at least 12 months (or until death) that place the individual at significant risk of death, acute exacerbation/ decompensation, or functional decline. The exact list of chronic conditions have not been established.
  • Your patient is required to sign a consent form acknowledging you as their exclusive CCM provider.
What must be done each month to qualify?
  • Provide 20 minutes of non-face-to-face Care Management Services. CMS recommends providing the following services each month. Keep in mind, the list is not exclusive; other services that the provider deems necessary to keep their patient health are considered acceptable. These services may be rendered by licensed clinical staff subject to proper supervision. Licensed clinical staff includes APRNs, PAs, RNs, LSCSWs, LPNs, CNAs and certified medical assistants.
    1. performing medication reconciliation and overseeing the patient’s self-management of medications
    2. ensuring receipt of all recommended preventive services
    3. monitoring the patient'’s condition (physical, mental, social)
  • Document the care provided. There are no exact requirements on what must be documented, but a provider would be well served to record the date and amount of time spent providing non-face- to face services (preferably start/stop time), individual rendering services, and a brief description of services.
  • Create and maintain the electronic Care Plan. The plan should include a list of current practitioners and suppliers that are regularly involved in providing medical care to the patient, the assessment of the patient’s functional status related to chronic health conditions, the assessment of whether the patient suffers from any cognitive limitations or mental health conditions that could impair self-management, and an assessment of the patient’s preventive healthcare needs. The plan should address all health issues (not just chronic conditions) and be congruent with the patient’s choices and values. The must be accessible 24/7 to the entire care team (fax does not count) and the patient. A paper or electronic copy must be made available to the patient
  • Ensure 24/7 access to Care. Provide a means for the patient to access a member of the care team on a 24/7 basis to address acute/urgent needs in a timely manner. A provider should also ensure that the patient is able to get routine appointments with the appropriate practitioner. Additionally, you must provide enhanced opportunities for patient-provider (or caregiver-provider) communication by telephone and asynchronous consultation methods (i.e secure messaging, internet).
  • Facilitate transitions of care as needed. This entails following up with the patient following an ER visit, provide TCM services, coordinate referrals and share information with other providers as necessary.
  • Coordinate care as needed. You must coordinate with home and community-based clinical service providers to meet the patient’s psychosocial needs and functional deficit (i.e. home health, hospice, outpatient therapies, durable medical equipment, transportation services, nutrition services).
Once these services are provided and well-documented, you will be able to bill Medicare each month for each qualifying patient. This is a pleasant change that focuses on prevention and less on treatment. Now, if this seems like it is outside of your current operation, you may find it worthwhile to outsource these types of services. Several companies have begun partnering with physicians to ensure that their patients are receiving the highest level of care.

Additional Reading
Profit from Chronic Care Management without actuallying doing anything.
Want $100,000 more per year? Provide Chronic Care Management Services.

Fact sheets: Proposed policy and payment changes to the Medicare Physician Fee Schedule for Calendar Year 2015
Providing and billing Medicare for Chronic Care Management Services


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