Chronic Care Management

Chronic Care Management

Chronic Care Management

CMS commenced the provision of Chronic Care Management to physicians in January 2015. This multilayered care initiative is targeted to Medicare patients 65 years and older with 2 or more chronic disease states and has been slow to be taken up by physicians as an added service.

Patients suffering with 2 or more chronic conditions are the biggest spenders of the health care dollar and preventive programs such as Chronic Care Management have been shown to reduce health care spending. Patients become increasingly proactive in managing their own health conditions with the support of a health assistant who calls them each month to check on their preventive screening, their functional ability and medication compliance.

At the office level, implementation of Chronic Care Management can mean little to no time required on the part of the office when a 3rd party provider is used.
We offer Chronic Care Management services that are easy to implement into your practice, provide an additional layer of care to patients as well as recurring revenue.

What is Chronic Care Management?

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Chronic Care Management (CCM) is defined as services provided to Medicare patients out of office, in a non face to face setting. Typically this exchange occurs as a minimum of 20 minutes of care provided as a phone call to the patient and/or electronic communications. The purpose of CCM is to improve care coordination with the patient as well as other health care providers.

Medication compliance is also an important aspect of CCM services. As physicians are aware, many hospitalisations occur due to poor medication compliance. Our CCM service helps patients adhere to their medications via the use of a smart phone app that prompts them to take each dose of their medication.

As part of CCM services, the patient must also have access to care providers 24 hours a day, 7 days a week as well as their care plan. The Care Plan is accessible to all care providers as well as the patient and information is updated by the CCM vendor with each patient interaction. 24 hour access to care is a huge benefit to both the patient and practice. The patient must have access to speak to someone at anytime regarding any acute condition associated with their chronic disease and this availability is conveniently provided by the CCM vendor.

This service is valuable for elderly with carers. The information from CCM services can easily be shared with carers to ensure they have up to date access on their loved one and empower them to also support patient health and well being. The 24 hour care assistance can also provide peace of mind for carers.

Only one physician can bill for any single patients CCM services and the service is not specific to any practice specialty. Primary Care Physicians and Internal Medicine doctors are well placed to provide CCM services and are best placed for care coordination. Many Cardiologists and other specialists see the benefit in provision of the service for enhancing patient care and practice revenue and are also actively adding this as a solution for their office.

Maximize Clinical Outcomes

  • Adopt a more proactive and informed approach to the management of their chronic conditions with the additional support of CCM services
  • Ensure patients become more compliant with their medications through better understanding of their medications and their dosage schedule
  • Provide peace of mind to patients that they can access health advice at any time day or night.

Enhance Patient Loyalty

  • Patient’s perceive the care is coming from your practice
  • Creates a higher quality of time with the patient when seeing the physician
  • Patients receive multiple benefits from enrolling in the program
  • Patients are more empowered to be proactive with their health and wellbeing
  • Carers can gain access to information to aid with care coordination.

How Does It Work?

allergy bannerOnce your practice is signed up the CCM vendor gains read only access to your EMR. This access is HIPAA compliant and secure. The vendor collates all the data and will use a Care Plan as the foundation of the care that is provided. The Annual Wellness Visit report is the perfect document to be used as the Care Plan. The vendor will also liaise with other providers for the patient to ensure that all records are complete and accurate.

The physician and patient will have access to the care plan and any updates from the patient’s providers. The vendor will also assist in managing transitional care visits to minimize the likelihood of the patient returning to hospital and ensures capturing this revenue.

Once the patient is setup, monthly calls will commence where 20 minutes of out of office care is provided by way of a telephone call and electronic communications.

For those patients with smart phones, an app is also available to help monitor their medication compliance. The patient will receive a prompt that reminds them to take their medication. The patient can opt for a reminder if they are not able to immediately take their dose or they can choose to skip the dose. This important feature will help patients become more compliant with their medications and help reduce hospitalizations due to poor compliance.

The patient will also receive information from the CCM provider on how to access their information as well as the call in number for 24 hour assistance.

The physician can log into the portal at any time to review patient information and check for any updates. All information is updated by the CCM vendor who liaises with the patient and their providers to keep the information current.

The CCM service will ensure continuity of care for the patient amongst their team of health care providers. Patients will also be more active in having their preventive services performed through scheduling via their phone app and reminders. Their Health Care assistant will also be prompting the patient to have their preventive services and aid in scheduling of these services.

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Typically the average reimbursement is $42 per patient per month as a national average billed on the 99490 code. This means for every 500 patients enrolled in the program, monthly revenues of over $20,000 per month will be seen by the practice.

Increase Revenue And Profit For Your Practice

  • Bill monthly on the 99490 code for each patient enrolled who successfully receives their 20 minutes of care
  • Recurring monthly revenue for the practice
  • National average of $42 per patient per month from Medicare
  • Ensure capture of transitional care
  • $20,000 per month in recurring revenue for every 500 patients enrolled in the program.


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The patient is responsible for a 20% copay that will be collected by the office. The patient is also free to opt out of the program at anytime should they request to do so. Patients do get excellent value for the program due to the many tangible aspects of care and the flow on effect to better health and wellbeing.

Easy to use reimbursement codes

1) Complete the agreement form and practice contact information

2) Determine a time for in office training

3) Begin enrolling patients and let your vendor do all the work

4) Bill out at the end of the month after receiving your vendor report

5) Experience the satisfaction of your patients, the improved loyalty and increased practice profitability

In Summary

Chronic Care Management is an important solution for improving patient health, independence and confidence. Increased communications with the patient around their health with knowledgeable professionals empowers the patient. As a physician, you will see the improved interactions with your patients and patient loyalty and increase in preventive service screening, further adding to your practice revenue.