An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Chronic disease is prevalent among Medicare beneficiaries, with most beneficiaries having multiple chronic conditions, which increases the risk for poor health outcomes such as mortality and functional limitations.

The Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management (CCM) as one of the critical components of primary care that contributes to better health and care for individuals, and holds promise for reducing overall health care costs. In January 2015, CMS adopted a new service code to improve payment and access to CCM services for Medicare and dual eligible beneficiaries who have two or more serious chronic conditions.

CCM has been payable since 2015 under CPT code 99490. This code allows eligible practitioners and suppliers to bill for at least 20 minutes of non-face-to-face clinical staff time directed by a physician or other qualified health professionals each month to coordinate care for beneficiaries who have two or more serious chronic conditions that are expected to last at least 12 months. In November 2016, CMS announced rule changes to the Medicare Physician Fee Schedule in response to feedback and insights from health care professionals across the United States to enable reimbursement for more complex and more time-intensive chronic care coordination effective. 

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The Problem With Delivering Chronic Care Management

A successful CCM program requires more than people to make the monthly calls and technology to track and document time.  The two critical success factors, which are often missing, are clinical guidelines and workflow.  Why are they so important?  CCM callers need guidance on what to say and what to do in order to consistently provide real value to patients. Protocol-based clinical guidelines are necessary to direct the patient dialog, so CCM callers know what to say to patients and are also alerted when patient responses indicate a potential escalation.  Workflow ensures optimal profitability by maintaining operational efficiency and ensuring that the twenty-minute time threshold is met with each patient (without overly exceeding it).

Masscare’s Innovative approach

MassCare’s approach is to hire and install a highly trained, professional Care Consultant into each qualifying Provider’s office to manage the CCM program.  After your final interview and hire, each Care Consultant undergoes comprehensive training and is provided with on-going support from MassCare’s central office team.

In support of the CCM program, MASS provides the following services:

  • Initiating Visit - Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of chronic care management (CCM) services.

  • Structured Recording of Patient Information Using Certified EHR Technology – We work within your certified EHR to provide structured recording of demographics, problems, medications and medication allergies. A full list of problems, medications and medication allergies in the EHR informs the care plan, care coordination and ongoing clinical care.

  • 24/7 Access & Continuity of Care - Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week. Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.

  • Comprehensive Care Management - Care management for chronic conditions including systematic assessment of the beneficiary’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications.

  • Comprehensive Care Plan - Creation, revision and/or monitoring (as per code descriptors) of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues. Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary’s care. A copy of the plan of care must be given to the patient and/or caregiver.

MassCare provides a comprehensive CCM solution for providers.