Overview of Chronic Care Management

Implementing a successful chronic condition management program is not inherently straightforward. To build a solid care model, you'll want to gain an understanding of the evolution of CCM, coding guidelines, and foundational concepts.

The purpose behind the inception of chronic care management was to provide a means of compensation for physicians and their organizations that were already caring for patients outside of the average office setting. As care teams collaborated outside the confines of a brick-and-mortar facility, patients with persistent and complicated diseases were able to reduce treatment costs while improving their health. Examples of positive patient outcomes include increased access to appropriate medical resources, enhanced communication with members of their care team, reduction in emergency room visits and hospitalization or readmissions, and increased engagement in their own healthcare.

What is Chronic Care Management: Key Concepts

CMS defines chronic care management as:

"Care coordination services done outside of the regular office visit for patients with multiple chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbations/decompensation, or functional decline. These services are typically non-face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month."

In addition to chronic care management, common care management services include remote patient monitoring (RPM) and transitional care management. (Learn definitions of other common CCM and preventive services terms in this glossary.)

To qualify for chronic care management participation, patients must be diagnosed with two or more covered chronic health conditions that are expected to last for at least 12 months or until the death of the patient.

To qualify for chronic care management participation, patients must be diagnosed with two or more covered chronic health conditions that are expected to last for at least 12 months or until the death of the patient.

Since the provision of CCM falls under Medicare Part B, both original Medicare and Medicare Advantage plans reimburse practitioners when CCM services are provided to eligible beneficiaries. Other requirements must be met to code, bill, and get paid for CCM. Learn about these rules and more in this Chronic Care Management Coding and Billing Guide.

What is a CCM-Eligible Chronic Condition?

As stated, chronic health conditions that are expected to last for at least 12 months or the lifetime of the patient can typically qualify a patient for chronic care management — if the patient is managing two or more diseases. Importantly, Medicare criteria must be satisfied. There is no set list of what conditions qualify under the criteria, but some common examples include:

• Alzheimer's disease
• Arthritis
• Asthma
• Cancer
• Dementia
• Depression
• Diabetes
• Heart disease
• Hyperlipidemia
• Hypertension
• HIV/AIDS
• Parkinson's Disease

Overview of Non-Complex and Complex CCM

While we will take a deeper dive into coding and billing for chronic care management later in this guide, understanding some coding and billing fundamentals can help one better understand the concept of CCM. The chronic care management service period is one calendar month. This means that practitioners may choose to submit a claim at the conclusion of the service period or after completing the minimum required service time.

Let's examine the basic (i.e., "non-complex") chronic care management codes: CPT 99490 and CPT 99491. Both require that the enrolled patient receiving services has two or more chronic conditions that are expected to last at least 12 months or until death; the chronic condition must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and a comprehensive care plan must be established, implemented, revised, or monitored. Finally, patients must provide explicit consent to enroll them in a CCM program.

Let's examine the basic (i.e., "non-complex") chronic care management codes: CPT 99490 and CPT 99491. Both require that the enrolled patient receiving services has two or more chronic conditions that are expected to last at least 12 months or until death; the chronic condition must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and a comprehensive care plan must be established, implemented, revised, or monitored. Finally, patients must provide explicit consent to enroll them in a CCM program.

It's important to note that while physicians, certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants may all bill for CCM services, only a single practitioner may receive reimbursement per patient for CCM services for a given calendar month. Additionally, this practitioner must only report either non-complex or complex CCM for a given patient for the month.

The 2022 Physician Fee Schedule final rule delivered a significant increase in reimbursement for some chronic disease management services and finalized the addition of new CCM CPT codes. To learn more about the substantial changes to CCM, watch this webinar, which outlines the final rule's most significant developments related to care management and telehealth.

To understand more about the evolution of CCM and its coverage, let's review the current landscape through a historical lens.

CMS Throws Its Weight — and Wallet — Behind Chronic Care Management

A close read of the 2022 Medicare Physician Fee Schedule proposed and final rules show that CMS is increasingly demonstrating support for chronic care management. This evolution can be seen in the agency's willingness to accept the RVS Update Committee (RUC) recommended update values for 10 codes in the chronic care management family. Though not uncharacteristic for a rule, the justification includes language rarely used by CMS.

The agency stated that it was proposing to boost reimbursement because doing so would be:

"Consistent with our goals of ensuring continued and consistent access to these crucial care management services and acknowledges our longstanding concern about undervaluation of care management under the physician fee schedule."

Such language is a clear indicator of the agency's support for CCM. What's also noteworthy is that physician fee schedule rules are extensively reviewed and dissected by many committees, so there were many opportunities for this language to be removed. Since it was left in the proposed rule, it's safe to say that CMS recommending significant increases in payment for these services indicates that CCM has gained traction as a long-term care management strategy.

The final payment update, which echoed what was proposed, significantly increased reimbursement for the chronic care management CPT codes.

Growing Support for Chronic Care Management

The increase in reimbursement is just one way CMS has demonstrated its support for chronic condition management in recent years. The 2022 proposed rule identified several ways CMS has strived to support CCM in the past, including the 2014 ruling to finalize a unique payable HCPCS code for CCM, HCPCS GXXX1, and the 2015 adoption of separate payment for CCM services under CPT 99490.

CMS has continued to build on support for CCM reimbursement over the years in the following ways:

1. For 2017, CMS adopted complex chronic care management (CCCM) CPT codes 99487 and 99489.
2. In the 2019 Physician Fee Schedule final rule, CMS adopted new CCM CPT code 99491. This code reimburses physicians for performing 30 minutes of CCM care a month.
3. In the 2020 final rule, CMS established payment for an add-on code to CPT code 99490 by creating HCPCS code G2058. CMS also created two new HCPCS G codes: G2064 and G2065.
4. In the 2020 final rule, CMS established payment for an add-on code to CPT code 99490 by creating HCPCS code G2058. CMS also created two new HCPCS G codes: G2064 and G2065.

This brings us to 2022, for which CMS added coverage for the following five new CPT codes: CPT 99437, CPT 99424, CPT 99425, CPT 99426, and CPT 99427. Read more about what these codes encompass and other key takeaways from the 2022 Physician Fee Schedule (PFS) final rule here in a column authored by Prevounce Co-Founder Daniel Tashnek for Physicians Practice. With the final rule solidifying the reimbursement increase, CCM has become one of the most lucrative — and, one could argue, clinically beneficial — Medicare programs. To understand more about how practitioners are implementing CCM, let's look at one of the most common co-existing chronic diseases that qualify many patients for a CCM program.

Chronic Care Management in Hypertension Management

To gain a better understanding of how chronic care management is benefiting patients, providers, and our healthcare system as a whole, let's look at how it's being used for one particularly common chronic disease.

• Hypertension arises when blood pressure begins to rise on a consistent basis, and too much force starts pushing against fragile blood vessel walls. More Americans than ever before (in fact, more than 100 million) have often-silent chronic high blood pressure, which leads to serious secondary health issues, such as heart attacks, strokes, and even heart failure.
• Of the Americans who have been diagnosed with hypertension, only about one-quarter have the condition under control. With the lack of obvious symptoms, hypertension is often taken and treated less seriously than it should be. Practitioners have long encouraged their patients to change this thinking and self-monitor hypertension symptoms from home.
• While self-monitoring is good, having patients log readings and take prescription medicine doesn't always provide the direct oversight or support that many people need to stay on track with hypertension monitoring and management. Practitioners and their clinical teams also found themselves spending countless hours coaching their patients outside of normal office visits — up until recently, that time spent wasn't reimbursable by most payers or Medicare. That's where chronic care management for hypertension management comes in.
• CCM provides a better method for practitioners to provide quality and supportive wraparound care for patients while also receiving fair compensation. In 2015, Medicare began paying practitioners for the CCM services provided to those Medicare beneficiaries with two or more qualifying diagnoses, many of whom had hypertension as a chronic condition. Recently, as we noted, Medicare expanded CPT codes further, adding new CPT codes to include complex chronic care management and principal care management (PCM).

With earlier treatment and better management of hypertension using CCM, patients can experience drastically improve outcomes — and providers can finally be appropriately reimbursed for their working supporting patients with hypertension. With so many benefits to be gained from chronic care management, one might assume that widespread adoption is pervasive. That seems to be the case only when practitioners understand the value of implementing a program.