Chronic Care Management Services, Part One

Earlier this year, I received correspondence from several readers of this column expressing appreciation for some of the editions of From the Field featuring an educational theme. Additionally, the reimbursement landscape is changing from fee for service to pay for performance. With this in mind, this edition of From the Field will focus on the ins and outs of one of the newer programs geared toward patient focused care, Chronic Care Management. As this is a large topic with many points to consider, the next edition of From the Field will cover implementation, billing, and reimbursement questions surrounding Chronic Care Management.

What is Chronic Care Management?

Chronic Care Management (CCM) is the provision of care management and coordination services to patients with two or more chronic conditions expected to last at least 12 months or until death, that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Generally, primary care physicians provide CCM services. However, in many cases, the nephrologist becomes the equivalent of a primary care provider for patients with chronic kidney disease. Additionally, nephrologists and their staff are already accustomed to providing some of the components of CCM services.

Examples of chronic conditions:

·        Diabetes·        Osteoporosis
·        Hypertension·        Hyperlipidemia
·        Cardiovascular Disease·        Alcohol Abuse
·        Depression·        Asthma
·        Heart Failure·        Drug/Substance Abuse
·        Chronic Kidney Disease·        COPD

Who Can Provide CCM Services?

Physician or non-physician practitioners (physician assistants, nurse practitioners, clinical nurse specialists and/or certified nurse midwives) and their clinical staff can provide CCM services. CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner (as an integral part of services provided by the billing practitioner), subject to applicable state law, licensure, and scope of practice.

Elements of CCM Services

CCM Services are comprised of several elements. The very first of those is the initiating visit. This visit can occur during an annual wellness visit, preventive physical exam, or any other face-to-face visit with the billing practitioner. Patient consent is one of the integral components of CCM services, as obtaining consent provides an opportunity to ensure the patient is engaged in their own care and is aware of possible cost sharing associated with CCM services. Many patients receiving CCM services have coverage through Medicare. As with most Medicare services, CCM services are subject to Medicare deductibles and coinsurances.

The initial conversation with the patient regarding consent is a great time to educate the patient that while many providers may be involved in the patient’s care, only one provider can furnish CCM services each month. Patients should also be aware they can stop CCM services at any time they choose (effective at the end of the calendar month).

Recording patient health information such as demographics and medications using certified Electronic Health Record (EHR) technology and developing a comprehensive care plan for the patient are also building blocks of CCM services. Comprehensive care plans may include things such as a problem list, medication management, measurable treatment goals, and a schedule for periodic review and applicable revision of the care plan.

Additional elements of CCM services are access to care and care continuity. Patients receiving CCM services should have 24-hour-a-day, 7-day-a-week access to physicians or other qualified healthcare professionals or clinical staff and a method to contact healthcare professionals in the practice to address urgent needs. Enhanced methods of communication via telephone, secure messaging, or secure electronic patient portals may help to facilitate access to a patient’s care team. Continuity of care can be ensured by designating a member of the patient’s care team with whom the patient is able to schedule successive routine appointments.

The final two elements of CCM services are comprehensive care management and transitional care management. Comprehensive care management may include an assessment of the patient’s needs, medication reconciliation,n and care coordination with home and community-based services providers. Transitional care management may include managing the transitions between and among home health care providers and the timely exchange of continuity of care documents with other practitioners and providers.

Sarah Tolson is the director of operations for Sceptre Management Solutions, Inc., a company specializing in billing for outpatient ESRD dialysis programs, nephrology practices, and vascular access. Your questions are welcome and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website,