From the Field: Care Management Services

Each year, as part of the service my company provides to our clients, I review the CMS physician fee schedule for the upcoming year as well as the ESRD PPS final rule. I also provide summaries to our clients outlining the changes and updates that are pertinent to their day-to-day business. This year, our nephrology practice clients were most interested in learning about the additional reimbursement opportunities possible via care management service that Medicare covers and the additional codes that have been added for care management services. Many of the nephrologists I speak with find they are already performing some of the elements of care management, and with a little effort, they can obtain reimbursement for care they are already providing to their patients. In this column, we will review the three types of care management covered by Medicare: Transitional Care Management, Chronic Care Management and Principal Care Management.

Transitional Care Management

Nephrologists who round in hospitals are likely already providing some of the elements of Transitional Care Management (TCM) services. TCM services are designed to support the transition of a patient who has been hospitalized back to the community setting, accepting responsibility for patient care at post-facility discharge without a service gap where moderate or high complexity medical decision making is beneficial to minimize the likelihood of hospital readmission. This care management category contains two procedure codes.

TCM services do require a face-to-face visit within a specified time frame from the patient’s discharge and there are non-face-to-face services that can be provided by non-physician practitioners (NPP) such as nurse practitioners and physician assistants as well as auxiliary personnel under the supervision of the physician or NPP. TCM services are a great fit for many nephrology practices because they can be billed in the same month as the Medicare Capitated Payment (MCP) for ESRD patients.

Chronic Care Management

CMS began reimbursing for Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM) services to promote better health outcomes for individuals with multiple chronic conditions. CCM and CCCM services have several similarities to MCP services in that they are charges that cover services rendered for an entire month, and the provider billing for CCM and CCCM services is responsible for overseeing the patient’s care and coordinating with other specialists the patient may need to see. This category of care management contains six procedure codes, one of which is new for 2022.

CCM and CCCM services are only reimbursable to one provider each month. To alleviate multiple providers rendering CCM and CCCM services at the same time, patient consent to receive CCM or CCCM services and acknowledgement they will be responsible for some cost sharing are required elements for coverage.

Several of the practices my company bills for have begun providing CCM and CCCM services to their level three and level four chronic kidney disease (CKD) patients as members of that patient population often have at least one other chronic condition.

CCM and CCCM services do have several required elements that may be time prohibitive for some practices to undertake. For practices that feel CCM and CCCM services would be a great service to offer patients but need assistance in doing so, there are third-party services that can help with different aspects of CCM and CCCM services.

Principal Care Management

Principal Care Management (PCM) services are similar to CCM services yet are different in that the patient is only required to have one chronic condition that the provider is managing. PCM services require either thirty minutes of healthcare professional time or clinical staff time where the staff are directed by a qualified healthcare professional each month. Acute kidney failure and CKD are both eligible conditions for PCM services. All procedure codes for PCM services are new in 2022.

As of the time of this writing, there are 12 codes for care management services covered by Medicare. Each procedure code has its own guidelines and requirements for coverage that providers, ancillary staff and billers should be familiar with to ensure all guidelines for coverage and reimbursement are met. Another important note is that not all insurance carriers cover care management services.

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 interventional nephrology. Your questions are welcome, and she can be reached at [email protected], 801.775.8010, or via Sceptre’s website,