WHITE PAPER The Complete Guide to Chronic Care Management How to improve patient care, while generating new, recurring revenue. WHITE PAPER | The Complete Guide to Chronic Care Management THE PROBLEM Seven of the top 10 causes of death in 2010 were chronic diseases1. The elderly are more likely to have chronic conditions with over 2/3 of Medicare beneficiaries having 2+ chronic conditions2. In fact 93% of Medicare dollars spent are on patients with 2 or more chronic conditions2. These chronically ill patients have the highest hospitalization rate, the highest readmissions rate, are the highest utilizers of home health services – the list goes on. As the number of conditions increase, so do the number of specialists and other providers treating these patients. In fact, 55% of chronically ill patients see 3+ physicians with 11% seeing over 6+ patients3. Coordinating efforts between various members of the care teams becomes a challenge—poor handoffs can result in redundancy in medications, unclear instructions, fragmented data, and general confusion. Figure 1: Figure 2: % of Total Medicare Spending ($587B in 2014) Number of Physicians Utilized (% of Patients) 46% 15% 23% 6% 11% 28% 26% 3% 16% 19% 7% 0-1 2-3 4-5 6+ THE SOLUTION Care coordination, or facilitating the patients' care activities between encounters (such as office visits), is a critical part of managing the increasingly complex handoffs that occur while delivering care for chronically ill patients. Care coordination is an evidence-based practice that has been shown to significantly improve clinical outcomes in both a primary care and acute care setting. A 9-month pilot by the American Academy of Family Physicians (AAFP) showed that telephonic nursing support improved clinical quality across 15 different HEDIS measures4. CAREHARMONY / 2 WHITE PAPER | The Complete Guide to Chronic Care Management Table 1: Pilot Results Versus National Best Practices Pilot Baseline Pilot Performance HEDIS National Category Measure (December 2001) (September 2012) Best Practice* 1 Diabetes A1C screening 88% 95.9% 93% 2 Diabetes A1C < 7.0% 49% 55.1% n/a 3 Diabetes LDL Screening 85% 91.9% 89% 4 Diabetes LDL < 100 54% 58.9% n/a 5 Diabetes Nephropathy Screening 89% 94.8% 88% 6 Diabetes Eye exams 34% 70.3% 74% 7 CAD LDL screening 84% 92.4% 92% 8 CAD LDL < 100 59% 66.1% n/a 9 Prevention Colon cancer screening 67% 72.1% 70% 10 Prevention Breast cancer screening 74% 78.0% 76% 11 Prevention Cervical cancer screening 41% 46.8% 82% 12 Prevention Osteoporosis screening 82% 88.1% 82% 13 Prevention Pneumovax 78% 85.8% 82% 14 Prevention Flu vaccine 54% 65.3% 61% 15 Prevention Tobacco counseling 55% 78.4% 84% *Commercial 2012 HEDIS 90th Percentile Targets The Center for Medicare and Medicaid Services (CMS) decided to use care coordination to help improve outcomes and reduce cost for their chronically ill patients – on January 1st, 2015 CMS introduced the new Chronic Care Management (CCM) program, for the first time reimbursing for non-face-to-face, telephonic care. CPT 99490: Chronic Care Management 99490 reimburses physicians for the following: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Patient has multiple (two or more) chronic conditions expected to last at least 12 months, or until death Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline Comprehensive care plan established, implemented, revised, or monitored Unlocking the Revenue Potential of 99490 Practices can earn $40.82/month2 providing CCM services for qualified patients, which translates to more than $240K per year with 500 enrolled patients. CAREHARMONY / 3 WHITE PAPER | The Complete Guide to Chronic Care Management The full scope of service and billing requirements for CCM contains over 10 items, but the key requirements for launching a successfully CCM program are listed below: ELIGIBILITY AND ENROLLMENT REQUIREMENTS Provider Eligibility Providers eligible to bill 99490 for their patients include: Physicians (MD,DO) Clinical Nurse Specialists Physician Assistants Certified Nurse Midwives Nurse Practitioners Although the concept of CCM most closely aligns with primary care and lays the foundation for a Patient Centered Medical Home (PCMH), there are no restrictions on what specialties can bill for CCM. This means that specialists in additional to primary care physicians and family medicine practitioners can bill for 99490 as long as they meet the CCM requirements. The one caveat to provider eligibility is that only a single practitioner may be paid for CCM in a given calendar month. Even if a patient is seeing multiple physicians (both a primary care physician as well as numerous specialists), only one of the patient’s physician can enroll the patient in CCM and bill for that patient. Patient Eligibility Patients need to have two or more “chronic” conditions. A chronic condition can be defined as a condition that: Is expected to last at least 12 months, or until the death of the patient Places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline There is no strict list of qualifying conditions – a condition just has to meet the above two criteria. The below CMS chronic condition list is a starting point for qualifying conditions: Table 2: CMS Chronic Conditions Acquired Hypothyroidism Asthma Ischemic Heart Disease Chronic Kidney Disease Heart Failure Cancer, Breast Acute Myocardial Infarction Atrial Fibrillation Osteoporosis Chronic Obstructive Pulmonary Disease Hip / Pelvic Fracture Cancer, Lung Alzheimer's Disease Benign Prostatic Hyperplasia Rheumatoid Arthritis / Osteoarthritis Depression Hyperlipidemia Cancer, Prostate Anemia Cancer, Colorectal Stroke / Transient Ischemic Attack Diabetes Hypertension Cataract Glaucoma Cancer, Endometrial Alzheimer's Disease, Related Disorders, or Senile Dementia This list is non-exhaustive—even conditions such as Obesity may qualify if they meet the two criteria. CAREHARMONY / 4 WHITE PAPER | The Complete Guide to Chronic Care Management Enrollment There are two main components to the enrollment process of a new patient; a face-to-face encounter with the patient and the signing of the consent form during that face to face visit. Face-to-Face Initiation of CCM CMS has explicitly mentioned that the following face-to-face visits are acceptable to initiate CCM services for a patient. Annual Wellness Visit (AWV) Comprehensive E&M Initial Preventive Physical Examination (IPPE) Transitional Care Management Consent Form A written consent form agreeing to be enrolled in CCM has to be signed by the patient before 99490 can be billed. The consent form and explanation to the patient about the CCM program must include the following information: Availability of CCM services Authorization for the electronic communication of the patient's medical information with other treating providers Existence of copay (if applicable) Right to stop the CCM services at any time (effective at the end of the calendar month) Only one practitioner can furnish and be paid for these services during a calendar month TECHNOLOGY REQUIREMENTS Electronic Care Plan A critical component of billing for 99490 is the creation of a comprehensive, patient-centered care plan that is based on the physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient. This care plan will assist the provider in providing “whole-person” care for the patient. 99490 cannot be billed without the electronic care plan in place and this care plan should be kept up to date during subsequent billings. The three key requirements for the electronic care plan include: Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record Ensure the care plan is available electronically (24/7) to anyone within the practice providing the CCM service Share the care plan electronically outside the practice as appropriate Certified EHR Any provider looking to participate in CCM has to have a certified EHR (e.g., ONC Certified) that satisfies the criteria of the EHR incentive program 2 years prior to the current year – this means in 2016 a provider would need a 2014 certified EHR. CAREHARMONY / 5 WHITE PAPER | The Complete Guide to Chronic Care Management SERVICE REQUIREMENTS Access to Care Managing chronic conditions and their flare-ups does not always neatly coincide with business hours. For this reason, CMS has made it mandatory that patients participating in CCM receive “24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s health record to address his or her urgent chronic care needs.” Access on the patient’s schedule, not the provider’s, is critical for avoiding unnecessarily ER utilization, such as ER use for urinary tract infections (UTIs). A study by the Henry Ford’s Vattikuti Urology Institute found that the average charge per patient for a UTI was approximately $2,000 per ER visit, $1,800 higher than the average cost of treatment in an outpatient clinic. The study concluded that giving patients greater access to primary care physicians could yield countrywide savings of nearly $4 billion a year on the basis of avoided UTI related ER visits alone5. Other softer requirements around access to care include: Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care (e.g., telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods) Billing 99490 cannot be billed simultaneously with a few other codes.