How Chronic Care Management Can Benefit Providers and Patients

In the United States, more than half of all adult patients have a chronic condition, and 1 in 4 Americans have 2 or more. Coordinating adequate care for these patients can be time-consuming, and this was the reasoning behind the introduction of chronic care management (CCM) to the CMS Physician Fee Schedule in 2015.

A session led by Irina Koyfman, DNP, NP-C, RN, at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2023 detailed the potential of CCM billing for physicians who are not currently doing it and recommendations for optimizing the process. Koyfman, who is the CEO of Affinity Care Expert, has been advising providers on use of CCM for years.

The main Current Procedural Terminology (CPT) code she focused on is CCM, which is billed monthly in 20-minute intervals and covers all of the care coordination activities that go along with treating complex patients with multiple chronic conditions. In 2019, she noted, CMS announced it had received positive patient and practitioner satisfaction feedback and cost savings attributed to the advent of CCM.

Still, because billing for CCM can be complicated, Koyfman noted that many physicians had stopped using it, prompting CMS to tweak the rules surrounding it, adding additional care management time beyond 20 minutes and no longer requiring a significant care plan change to bill for it.

In 2021, an additional code, Principal Care Management (PCM), was added to the roster. PCM, usually billed by specialists, can be billed for patients with 1 chronic condition and has a 60-minute-per-month minimum.

For CCM billing, patients with at least 2 chronic conditions that are expected to last at least 12 months or until the patient’s death, or conditions that place the patient at a significant risk of death, acute exacerbation, or functional decline can be included. This can include anything—from asthma to diabetes, cardiovascular disease, depression, cancer, and many more conditions that fit the requirements.

There are numerous activities that count toward the minutes billed for CCM, including forming a comprehensive care plan, care coordination, medication education and reconciliation, lab reviews, preventative care reviews, scheduling, specialist referrals, and more.

“Honestly, everything that is being done [for] the patient outside of the clinic is chronic care management,” Koyfman said.

There are a set of stipulations for physicians to adhere to, starting with having an initiating visit with the patient (ie, a Comprehensive Evaluation and Management, Annual Wellness Visit, or Initial Preventative Physical Exam) during which CCM is discussed. The visit should be billed separately.

Patients must also give either verbal or written consent to be treated under CCM stipulations, and they must be informed of potential billing implications from the patient cost-sharing perspective.

Once CCM is initiated, additional patient-facing provider responsibilities include assigning a designated care team member to the patient, maintaining a certified electronic health record, and providing some sort of coverage around the clock in case patients need assistance. Physicians must also form a comprehensive care plan.

All health issues must be in the care plan, not just those the physician is billing CCM for. This can include listing problems, prognoses, measurable treatment goals, assessment of patient cognition and function, symptom management plans, interventions, medical management, care coordination, and a periodic review schedule. Recently, environmental evaluation and caregiver assessment were added.

A major limitation of CCM is that it can only be billed by one physician per month, Koyfman noted.

“It's very important if you're going to think about implementing CCM and you call the patient, you want to ask, ‘Is anybody else calling you?’ And they'll say, ‘Oh, yeah, my cardiologist. The nurse calls every month.’” In this case, whichever provider bills first would be reimbursed, and the second provider’s claims would be denied.

Another important aspect is that only physicians and non-physician practitioners, such as certified nurse midwives, clinical nurse specialists, nurse practitioners, physician assistants, rural health clinics or federally qualified health centers, and hospitals and critical access hospitals can bill for CCM. Limited license physicians and practitioners like clinical psychologists, dentists, or podiatrists, for example, cannot bill for CCM.

Still, the clinical staff managed by the provider can provide the CCM services to patients under general supervision from the billing practitioner on an incident to basis.

Certain other codes can be billed with CCM, while others cannot, Koyfman noted. Transitional care and CCM can be billed together, but CCM cannot be billed with home healthcare supervision, hospice care supervision, or certain end-stage renal disease.

When implemented consistently, CCM can have a significant financial payoff for providers. If 100 patients stay on CCM for a year, for example, this could generate about $80,000 while also improving patient satisfaction with care, Koyfman noted.

Doing care coordination in-house vs outsourcing is another question, considering the workload of managing patients. Pros of outsourcing include quick implementation, a lower price tag because, no need for additional management, no need for any new technology platforms, and the scalability of outsourced help. Still, this option offers less ability to manage the team, less work visibility, potentially less integrity, less engaged providers, and less collaboration.

For physicians outsourcing CCM, it is crucial to evaluate the clinical team, technology platforms, billing practices, and fees. A clinical team with proper licensing, bilingual staff, open lines of communication, escalation protocol for incidents that need physician attention, the attrition rate, and their management.

“Why? I met a pretty large [CCM] vendor whose manager is… a veterinary technician,” Koyfman recalled, eliciting a collective gasp from the crowd. “A veterinary technician was managing nurses.”

Validating software is also important, with countless options of varying quality. The software’s reporting frequency and thoroughness; availability of a consent template, care plan, and clock for timing; EMR integration; and the software’s capabilities in terms of tracking multiple billing tracks are things to looks at. The fees also vary substantially, Koyfman noted.

Koyfman closed with a reiteration of best practices for successful and ethical CCM implementation that benefits both patients and providers, regardless of whether CCM is outsourced or done internally.

Regular team meetings, analysis of root causes of hospitalization and readmission, regular clinical conferences, and a designated person on the internal care team to be accountable for CCM activities—whether outsources or in-practice—are all key best practices, she said.

A range of challenges still exist in the space. Patient out-of-pocket costs can vary depending on insurance plans and lead to dissatisfaction, and patient reachout and enrollment can be challenging. Some patients may also not be engaged with CCM, or may agree at first but make follow-through challenging. In the same vein, providers may not be as involved with CCM as they can or should be. Verifying patient eligibility, which varies based on what else is being billed and whether another provider has already billed for it, is not always simple.