By Hitender Soni, Vice President, OmniMD
Twitter: @omnimd
Chronic diseases and conditions—such as heart disease, stroke, cancer, diabetes, obesity, arthritis—are among the most common, costly, and preventable of all health problems.
In the past, Medicare has only approved incentive payment for non-face-to-face chronic care management, CCM (such as medication reconciliation, coordination among providers, arrangements for social services, remote patient monitoring) — if the services were billed as part of face-to-face evaluation and management (E&M) services. As of January 1, 2015, that situation has changed. Medicare will now compensate providers for CCM under CPT 99490.
Nevertheless, costs for performing chronic care management are significantly high preventing practitioners from providing these vital services.
This results in patients with chronic conditions, very often left to manage their conditions by themselves between office visits. This asymmetrical method of chronic disease management leads to high costs of health management, leading to emergency room visits, hospitalization as well as deaths.
The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the indispensable components of primary care that contributes to better health, better outcome and care for patients, as well as reduced spending. Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.
Chronic care management services is defined as at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient.
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
- Comprehensive care plan established, implemented, revised, or monitored.
CPT code 99490 affords healthcare groups to bill CMS for services they were already providing essentially for free.
When the Centers for Medicare and Medicaid Services publicized that it would start paying, under CPT code 99490, for “non face-to-face care coordination services,” it was expected that providers will rush to cash in on what looks to be reasonably easy revenue.
However, that did not actually happen in the chronic care management program’s first year. One reason, of course, is that CMS only gave the industry about four months notice that 99490 would kick in on January 1, 2015 – and even then it was basically, if perhaps accidentally, promoted as a new Telehealth code.
One way to estimate the possible total is to multiply 36 million Medicare patients with two or more chronic conditions by roughly $40 dollars per month. CMS will pay for 20-minute consults and then multiply that by 12 months to arrive at: $17.2 billion every year.
That enormous total, however, requires that every single one of those 36 million patients register in a chronic care management program, then be treated via non-face-face means every month, and the provider has to track individual each session and bill accordingly.
Meaningful use incentives had mixed results, with CMS disbursing more than $30 billion to date which was paid to Hospitals and EHR vendors. Many EHR Vendors and Hospitals are looking for similar opportunities with CCM. They are using advanced technology to differentiate themselves and take benefit of CCM opportunities.
Until now only 13 percent of participants in a recent study have actually filed a 99490 claim and have been paid, according to research conducted by Enli Health Intelligence and the consultancy, Pershing, Yoakley and Associates.
CMS, will have to streamline a number of facts, such as billing to lessen the paperwork burden, define what can and cannot be counted as part of the 20-minute monthly consult, waive or reduce the co-insurance for participating, as well as market the value of CCM for patients and their families to make it easier for healthcare providers to enlist prospects with two or more chronic conditions.
Providers must automate the process of recognizing and informing qualified patients and then manage the care team workflow efficiently to confirm both proper follow-up and billing CMS for the visit.
CMS preliminary statistics predicts that Medicare covered 55.3 million people as of 2015 – around 69 percent of whom have two or more chronic conditions, which is a qualifying condition to enroll in CCM. CMS is predicting that number of total patients to rise steeply close to 80 million by 2030.
Despite the already widespread appreciation of CCM’s potential benefits, still only a very small percentage of participants have actually filed a 99490 claim and has been paid. But there is a bright future of CCM. Private payers may follow CMS lead and start paying for CPT code 99490, the market could effectually triple to $51 billion annually. CCM will drive innovations that healthcare providers can employ to engage patients, better manage populations and eventually improve care.
This article was originally published on OmniMD and is republished here with permission.