With regard to the Medicare Physician Fee Schedule (CPT 99490 / G0511), Chronic Care Management (also known as CCM) is the non face-to-face care for chronically ill patients that occurs between regular office visits in an effort to address many of the issues that prohibit a patient’s ability to manage their conditions. Chronically ill is defined as patients that have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.

Illnesses that are eligible for Chronic Care Management include, but are not limited to: Alzheimer’s disease and related dementia, Arthritis (osteoarthritis and rheumatoid), Asthma, Atrial fibrillation, Autism spectrum disorders, Cancer, Cardiovascular Disease, Chronic, Obstructive Pulmonary Disease, Depression, Diabetes, Hypertension, Infectious diseases such as HIV/AIDS.

Any medicare patient that has 2 or more chronic conditions is eligible for this program. Centers for Medicare and Medicaid Services (also known as CMS) guidelines simply require the patient to meet the following criteria: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or inability to manage their symptoms or condition itself.

CCM services include at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, for each patient that has met eligibility requirements as detailed by Medicare. Eligibility requirements are defined as: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. Chronic conditions place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline. A comprehensive care plan must be established, implemented, revised, or monitored.

CMS does not limit chronic care management to one practice area, however, primary care is the most common place for chronic care management to be offered. Any provider can implement and bill for chronic care management so long as patients receiving CCM are eligible to receive such services. Other practice areas could be gastroenterology and gynecology, where there may be a patient population that can support a chronic care management program.

CCM through Chronic Care Staffing is designed to minimize downtime for your staff, RNs, doctors and administrators. We can provide 100% of non face-to-face interaction so your doctors, RN’s and other staff members can focus 100% of their efforts on in house patient care and face to face appointments.

Many providers have an existing CCM program, but it likely is not achieving full potential due to two primary reasons: 1) Internal staff are constantly pulled to do other things in the office resulting in lower monthly billed calls. Successful CCM programs have a high ratio of monthly billing per enrolled patient. This often requires that each enrolled patient be called multiple times each month to be reached and complete the 20 minute call. Existing staff typically do not have the capacity required to reach each of the practice’s enrolled patients once per month, which limits the clinical effectiveness of the CCM program for the patient and the revenue opportunity for the provider. Practice’s attempting CCM internally only realized a 30-60% billed call rate for enrolled patients. 2) It is very expensive to recruit, train, and retain CCM Care Coordinators, which minimizes the provider’s profitability and its ROI on CCM services (1).

Outsourcing CCM allows for providers to place 100% of their focus on face to face visits. By outsourcing CCM with CCS, your practice will: 1) generate greater revenue 2) increase patient participation 3) retain a greater focus on face to face care.

While the goal of CCM is to generate more revenue for your practice and increase patient participation, it is also designed to help improve patient care and patient health outcomes. It is possible that some patients may be able to avoid office visits because they are better able to manage their chronic conditions, however, part of great patient care does require annual visits and face to face time with doctors.

Medicare typically reimburses roughly $40+ per month per billed patient. CCM services include structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

At Chronic Care Staffing, we focus on closing the gaps in care for your patients with CCM. We offer a comprehensive set of chronic care management services that includes: Increased Patient Education/Awareness, Identifying Patients in need of their Annual Wellness Visit (AWV), Assisting with Medication Refills/Reconciliation, Assisting with Verbal Enrollment Maximizing CCM patient participation, Assisting with Appointment Reminders, Documenting and Reporting Change in Patient Health Status, Referral Coordination, Transition of Care notice to Provider.

General Behavioral Health Integration (BHI), CPT 99484, is the non face-to-face care for Medicare and Medicare Advantage patients that have been diagnosed with any mental, behavioral health, or psychiatric condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services. The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

The Medicare Annual Wellness Visit (AWV), G0438 & G0439, is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors.

All Medicare and Medicare Advantage patients are eligible for an AWV annually. There is no cost sharing for an Annual Wellness Visit and can be applied to the patient’s deductible.

Chronic Care
Management Benefits
Outsourcing Chronic
Care Management
Patient Care
Generate Greater
Practice Revenue
Patient Monitoring
Highly Qualified
Care Coordinators
What is Chronic
Care Management?
Who is Eligible for Chronic
Care Management?