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.

Universal Medication Management

P5 Connect, Inc. is partnered with Universal Medication Management.

Chronic Care Management Program

Secure Written Consent
Written consent from eligible beneficiaries must be stored in the patient chart.
Have Five Specified Capabilities
Use a certified EHR (2011 or 2014), Maintain an electronic care plan, Ensure beneficiary access to care, Facilitate transitions of care, Coordinate Care.
Provide Monthly Services
20+ minutes of non-face-to-face care management services per calendar month. Services must be administered by a licensed clinical staff subject to proper supervision.
Providers
Physicians regardless of specialty, advanced practice registered nurses, physician assistants, clinical nurse specialists, and certified midwives.
Patients
Medicare recipient diagnosed with 2+ chronic conditions expected to persist at least 12 months and place the individual at a significant risk of death, acute exacerbation/decompression, or functional decline.
Non-face-to-face Chronic Care Management
CMS allows for the billing practitioner to arrange non-face-to-face CCM to be performed by clinical staff external to the practice, such as P5 Connect, Inc., as long as requirements for general supervision are satisfied. General supervision is described by CMS as availability to provide assistance as required.
Web Portal
P5 Connect, Inc. offers the practitioner real-time access to the web portal that would fulfill CMS’ general supervision requirement.
Date of Service
The billing practitioner may list as the date of service, the date on which the non-face-to-face requirement was satisfied, or any day thereafter within each calendar month.
Structured data recording
Comprehensive Care Plan
Creation of a shareable patient-centric comprehensive care plan including problem lists, symptom management, planned interventions, medication management, scheduling, and other services.
Multimedia Access
Access to care through enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care through multimedia access in compliance with HIPAA.
Ensure continuity of care
24/7 Access
Ensure 24/7 access to care management services, providing the patient with the means to make timely contact with the healthcare team.
Care Management Services
Any additional services required to fulfill the Non-Face-To-Face CCM requirements.
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Chronic Care Management Calculator

  • x % of patients with 2 or more chronic conditions (Alabama Average**)
    72.5
  • Estimated CCM Payments Per Month Per Patient (on Average)
    $43.00
  • Please enter a number from 0 to 100.
  • **Alabama Average Obtained from here.
    *This example calculation above is offered as an estimate of possible revenue generated by participation in Chronic Care Management through CMS.

Chronic Care Management Capabilities

Beneficiary Consent
Practitioner must obtain written consent that outlines the nature of CCM, beneficiary’s responsibilities (co-payments and deductibles), and the extent of said consent.
Customized Consent Form
P5 Connect, Inc. will provide your practice with a customized form that can be uploaded into the patient profile using our proprietary HIPAA compliant technology. A copy of the consent should also be maintained in the beneficiary’s EMR.
EHR for Specified Purpose

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);
Assistance with Collecting Demographic Information
  • 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 Requirement of an Electronic 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;
Assistance with the Electronic Care Plan

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.

Beneficiary’s Access to Care

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.
24/7 Access to the Web-Portal.

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.

Transition of Care

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.

Coordination of Care

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.

20+ Minutes of Non-Face-to-Face Time
  • Performing medication reconciliation and overseeing the beneficiary’s self-management of medication
  • Ensuring receipt of all recommended preventive services
  • Monitoring the beneficiary’s condition
Medication Reconciliation, Review and Education

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.

Become a Partner

Contact P5 Connect Today. 818.377.7406