Suite of services designed to improve patient health and increase practice revenue.

Chronic Care Management (CPT 99490 / G0511, G0511 for FQHCs)

Chronic Care Management (CCM) national reimbursement is $42.17 ($67 for FQHCs). CCM requires twenty minutes of non face to face monthly activity on behalf of enrolled patients. Who’s eligible? Any Medicare and Medicare Advantage patient with two or more chronic conditions.

  • Benefits to the Patient – Direct phone line to an assigned Care Coordinator who serves as an extra set of ears and eyes for the patient while closing gaps in care. Our nurses are trained to help manage the patient’s chronic conditions between office visits.
  • Benefits to the Client – Increased quality metrics and revenue, reduced clinical staff time tending to patients not in the office. Care Coordinators can be assigned monthly concentrations from client helping them complete Medicare required measurements.
  • Why use CCS? We assign the same Care Coordinator to the patient and their provider. This establishes a trust with the patient which allows the Care Coordinator to effectively coach the patients with lifestyle changes that improves managing their chronic conditions. An increased level of efficiency from Care Coordinators ensuring all enrolled patients are contacted every month. Industry leading experts who take a patient focused approach to Chronic Care Management. Chronic Care Staffing is on the forefront of compliance and CMS Care Management Services program changes.

Behavioral Health Integration (CPT 99484, G0511 for FQHCs)

Behavioral Health Integration (BHI) national reimbursement is $48.65. Monthly service guidelines are similar to CCM, including 20 minutes of non face to face activity on the patient’s behalf. Who’s eligible? Any Medicare and Medicare Advantage patient that has a 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.

  • Benefits to the Patient – Behavioral Health patients find it easier to speak with our psych trained Care Coordinators over the phone as opposed to the clinical setting. Many patients have stated that they are more comfortable communicating this way. They are also more likely to participate in a BHI phone call versus an appointment in the office.
  • Benefits to the Client – Behavioral Health patients have the highest rate of ER visits among chronic condition diagnoses. Managing this patient group is important in reducing overall costs attributed to your healthcare organization.
  • Why use CCS? For Pain Management/Opioid Prescription and chronically diagnosed patients with behavioral health conditions, CCS serves as an independent monthly consultation of your patients focusing on provider recommendation compliance, symptom recognition and management, patient-interactive goal setting/planning, condition self-management education, and patient-centered care planning by quality driven and highly skilled care coordinators

Annual Wellness Visit (G0438 & G0439)

Annual Wellness Visit (AWV) average reimbursement is $350 (with additional codes). This typically includes additional codes for patient assessments. AWV is service that includes a Health Risk Assessment (HRA) and brief patient exam that helps providers keep current with their patients healthcare. A Health Risk Assessment is one of the most widely used screening tools in the field of health promotion. All Medicare and Medicare Advantage patients are eligible for this annual service.

  • Benefits to the Patient – Patients get to complete HRA from the comfort of home over the phone with a highly skilled Care Coordinator. This unique service allows patients time to answer personal and valuable medical history without feeling rushed. This, in turn, reduces overall patient time at the practice, therefore, increasing commitment and completion of the AWV.
  • Benefits to the Client – Our nursing staff will spend time calling eligible patients performing HRA and setting up a brief in clinic AWV. This allows providers and office staff to focus on the day to day clinical operations. The higher percentage of patients that complete HRA/AWV the more likely quality metrics will be met.
  • Why use CCS? Maintain 15-minute office blocks for AWV appointment, execute an efficient AWV program without disrupting the daily clinical schedule, and full completion of the Health Risk Assessment questionnaire that is up to date and readily available in the EHR at the time of the patient encounter.

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?