Chronic Care Management
Beginning January 1, 2015, Medicare now pays for Chronic Care Management, or CCM. CCM payments will reimburse the practitioner for non-face-to-face services to qualified beneficiaries over a calendar month. CMS has adopted CPT 99490 for Medicare CCM services, which are defined as follows: “Chronic care management services, 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. Current Procedural Terminology (CPT) a registered trademark of the American Medical Association.
P5 Connect, Inc. has the technological and professional capabilities of assisting your practice with fulfilling the CCM services for qualifying patients. Please see the tables below for the summary of the CCM requirements as the services that P5 Connect, Inc. can provide in assisting the physician’s practice in providing CCM services.
P5 Connect, Inc. is partnered with Universal Medication Management.
Chronic Care Management Program
Chronic Care Management Capabilities
Must meet the following capabilities:
- Structured recording of demographics, problems, medications, and medication allergies, all consistent with 45 CFR 170.314 (a)(3) – (7);
- Creation of summary care record consistent with 45 CFR 170.314 (e)(2)
- The following must be documented in the beneficiary’s record using CCM certified technology:
- Beneficiary’s consent;
- Provision of care plan to beneficiary;
- Communication between home and community-based practitioners regarding beneficiary’s psychosocial needs and functional deficits (psychosocial coordination);
- P5 Connect, Inc. will assist the practitioner in collecting the demographic information.
- The information obtained will be stored in the database that will be accessible to the practitioner in real-time on a 24-hour basis.
- All information entered and maintained will be constantly updated to reflect the most current status.
- The information will also be available to home health practitioner and can be provided to any other physician when indicated and authorized to do so.
- Our staff will assist the provider with creating and updating the Care Plan.
The practitioner must develop and regularly update (at least annually) an electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental reassessment of the beneficiary’s needs.
The preparation and updating of the Electronic Care Plan is not part of the reimbursable service. These activities may be billed separately as an evaluation and management service.
Items that are typically included in the care plan:
- Problem list;
- expected outcome and prognosis;
- measurable treatment goals;
- Symptom management and planned interventions;
- Community/ social services to be assessed;
- Plan of care coordination with other providers;
- Medication management;
- Responsible individual for each intervention;
- Requirements for periodic review/revision;
The Medication Management Team will create a list of current medications and allergies, reconciliation with review of adherence and potential interactions, as well as the oversight of patient’s self- management.
CMS requires the practitioner to “use some form of electronic technology in fulfilling the care plan element.” P5 Connect, Inc. proprietary technology will allow the practitioner to comply with the CMS requirements of using some form of electronic technology. The web portal will assist not only with the creation of the care plan but will also allow for sharing with all other providers as well as real-time access and updates.
The use of P5 Connect, Inc., will fulfill the CMS requirement that the care plan must be electronically accessible on a 24/7 basis to all care team members furnishing CCM services billed by the practitioner.
P5 Connect, Inc. will allow the practitioner to have the capability to share the plan with other providers care for the beneficiary as well as the beneficiary as required by CMS.
The practitioner furnishing CCM must:
- Allow the beneficiary access to a member of a care team on a 24/7 basis.
- Provide the beneficiary with the ability to schedule appointments with the practitioner and / or a designated member of a care team.
- Provide enhanced opportunities for beneficiary-practitioner (caregiver-practitioner) communication.
Our experienced and knowledgeable staff will assist the provider with appointment scheduling as well as providing opportunities for the enhanced communication requirements.
The beneficiary, through the use of P5 Connect, Inc.’s technology, will receive secure text messaging reminders.
The web portal allows the beneficiary (and/or caregiver) to become an active participant in his / her care through real-time access to information and secure information sharing.
The practitioner must have the capability for the following:
- Follow-up with the beneficiary after an ER visit
- Provide post-discharge transitional care management services. *TCM and CCM cannot be billed during the same month
- Coordinate referrals to other clinicians
- Share information with other clinicians as appropriate
P5 Connect, Inc. will allow for information sharing and assisting the practitioner with coordinating referrals to other clinicians as well as providing additional clinicians with the necessary information.
Practitioner must have the capability to coordinate with home and community-based clinical service providers to meet the beneficiary’s psychosocial needs and functional deficits.
P5 Connect, Inc., through its technology, allows the practitioners the capability to coordinate care and communicate with home health, hospice, outpatient therapies, nutrition services, transportation services, and other service providers thereby reducing the burden on the practitioner.
- Performing medication reconciliation and overseeing the beneficiary’s self-management of medication
- Ensuring receipt of all recommended preventive services
- Monitoring the beneficiary’s condition
P5 Connect, Inc. and its staff will perform medication reconciliation with review of adherence and potential interactions as well as assist the practitioner in overseeing the beneficiary’s self-management of medication.
P5 Connect, Inc. provides patient education services and has the capability to address questions from patient, caregiver, and / or family member.