Managing the health of patients with chronic conditions is both time and resource consuming for physicians, who traditionally have spent time coordinating patient care outside of their daily duties and without reimbursement. In 2015, the Centers of Medicare and Medicaid Services (CMS) launched a program for chronic care management (CCM), which provided reimbursement for non-face-to-face services to Medicare beneficiaries with two or more chronic conditions.

Even though the CCM program was a step in the right direction toward improving the health of Medicare patients and reimbursing physicians for their services, there were still a few areas that needed to be revised. The amount of clinical staff time and the extent of care planning varied between Medicare patients in the CCM program, and often providers were not being adequately reimbursed for additional hours and services.

CMS addressed these concerns in the 2017 Physician Fee Schedule final rule that recognized the importance of improving CCM reimbursement for providers. The rule revised CCM payment, including adding new codes for complex chronic care management and for extra care management provided following the initiating visit for patients with multiple conditions. These revisions are significant to improving CCM reimbursement and will support primary care when and where patients need it most.

Complex CCM for 2017

Complex CCM service codes provide higher payment for Medicare patients with multiple chronic conditions. Patients who qualify for complex CCM have the following care requirements:

  • At least 60 minutes of clinical staff time
  • Substantial care plan revision and/or care plan establishment
  • Problems of moderate or high complexity during the calendar month that the billing practitioner needs to address

For Medicare patients with multiple chronic illnesses, the difference between qualifying for complex vs. non-complex CCM does not depend on having specific medical conditions. Instead, the difference between the CCM programs is the amount of clinical staff time, the extent of care planning, and the complexity of the problems addressed by the billing practitioner during the month.

New CCM complex code details

The new complex chronic care management code changes, which took effect Jan. 1, 2017, allow providers to be reimbursed for additional time and care management for complex cases as follows:

  • CPT code 99487 is for 60 minutes per month of clinical staff time directed by a physician or qualified healthcare professional. This includes ongoing oversight, direction, management and medical decision-making of moderate-high complexity. The reimbursement is approximately $94 per billing, per enrolled patient.
  • CPT code 99489 is an add-on code for CPT code 99487 for each additional 30 minutes per month of clinical staff time directed by a physician or qualified healthcare professional. The reimbursement is approximately $47 per billing, per enrolled patient.

To be eligible for Medicare payment, providers must meet the same requirements under both complex and non-complex CCM.

CMS raising awareness of CCM in 2017

In March 2017, CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources and Services Administration (HRSA) introduced Connected Care, an educational initiative to help raise awareness on the benefits of CCM services. CMS and HRSA began offering new resources to help educate both patients and providers on how to get started with the program and ways to get involved in the Connected Care initiative. Some of the resources include:

  • A provider toolkit with detailed information on the CCM program
  • Patient education materials including a poster and postcard for patient onboarding

The Connected Care initiative builds on CMS’ efforts to help providers care for patients with multiple chronic conditions. By providing resources for both patient and practice education, the Connected Care initiative aims to help increase the number of participating providers in the CCM program.

Benefits of 2017 changes to providers

The changes CMS made to the chronic care management program are intended to increase care coordination, provide the personalized consultative care patients need when suffering with complex conditions and improve clinical outcomes. Importantly for providers, the new codes increase reimbursement for services, generating additional revenue and experience in today’s value-based care landscape.

CMS listened to healthcare providers’ input on other CCM program elements as well. Along with adding complex care codes, they reduced the requirements associated with initiating care, increased payment when extensive initiation work is needed and significantly reduced the payment rules providers must follow when billing for CCM services. These changes enhance the program, make it easier for practices to enroll patients and remove more barriers to much-needed complex and non-complex chronic care management.

Learn how McKesson Chronic Care Management Services can help your practice improve quality care and increase value-based reimbursement.

Outlook for Chronic Care Management and Physician Payments in 2017

Bill Sillar

About the author

Bill Sillar is National Channel Manager for McKesson Business Performance Services, supporting McKesson’s value-based care services. Sillar has been with McKesson for 10+ years and has played a pivotal role in helping healthcare organizations bridge the gap as they transition from a fee-for-service to a value-based reimbursement payment model.