Care Transformation Center Blog

CCM codes: Are you leaving money on the table?

by Rebecca Tyrrell and Hunter Sinclair

About 99% of all Medicare dollars are spent on patients with chronic conditions. Until CMS introduced Chronic Care Management (CCM) codes in 2015, much of the work providers put into helping patients manage these conditions went uncompensated.

Now, providers have the opportunity to bill for non-face-to-face chronic disease management services for Medicare and dual-eligible patients with two or more chronic conditions. These non-face-to-face services might include coordinating referrals, taking inbound calls, scheduling appointments, reviewing medical records and test results, or exchanging information with other providers.

The codes are designed to enhance payment and improve access to more regular care management services, with a current focus on boosting use among underserved rural populations and racial and ethnic minority populations. Since providers may bill CCM monthly for each patient receiving services, the codes provide a mechanism for more regular patient-provider and provider-provider contact.

We've received a number of questions regarding the codes since they were introduced, and even more now that CMS has made changes to the program effective calendar year 2017. Here are some of the top insights we've gleaned:

1. CCM services are underutilized; providers are hesitant to invest upfront in resource requirements

Of the 35 million Medicare beneficiaries eligible to receive CCM services, claims were submitted for only 100,000 or so beneficiaries in the first year, or 0.2 percent of those eligible.

The primary reasons cited by those not submitting claims were burdensome IT requirements, uncertainty regarding who in the practice should manage, and concerns regarding patient co-pays and documenting patient consent.

Effectively, the benefits did not seem to outweigh the costs of figuring out how to best meet program requirements.

2. Administrative simplifications and payment enhancements should increase use in 2017

Under initial program design, patients could receive only regular or "non-complex" CCM (99490), which paid approximately $42. In 2017, CMS introduced three new codes (99487, 99489, G0506) to distinguish visits based on complexity and on whether they are "add-on" visits. Payment now ranges from $43 to more than $141 per beneficiary per month, depending on complexity.

Additionally, there are reduced requirements associated with initiating care, reduced payment rules for billing the services, and more flexible requirements around patient consent and technology usage. For example, CMS now allows documentation of verbal patient consent in the medical record instead of requiring written patient consent prior to billing for CCM services.

This enhanced revenue opportunity, combined with administrative simplifications, should incent more providers to begin offering this service.

3. Staff deployment options are variable, impacting financial returns

CCM services may be provided by a physician, PA, NP, CNS, or CNM, and their clinical staff. "Clinical staff" includes APRNs, RNs, LSCSWs, LPNs, clinical pharmacists, and medical assistants, assuming organizations meet "incident to" rules regarding supervision, applicable state law, licensure, and scope of practice.

Based on an analysis of primary care practices published in the Annals of Internal Medicine, revenue potential varies depending on who is furnishing services. According to the paper, if non-physician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. If physicians were to deliver all CCM services, revenue loss might result due to opportunity costs of face-to-face visit time.

To guide team deployment, consider available staff resources, the number of eligible patients within your practice, and which services are primarily being provided to your panel outside of face-to-face interactions.

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