What is Chronic Care Management?

According to the Center for Disease Control (CDC), nearly half of the adults in the U.S.—some 117 million people—have one or more chronic health conditions. This population accounted for 86 percent of healthcare spending. These means half of the country was responsible for 86 percent of the cost of care.

Recognizing an unsustainable pattern, the Centers for Medicare and Medication Services (CMS), the organization that sets reimbursement rates for Medicare (most private insurers follow suit) reviewed chronic care management and developed new standards and reimbursement codes to encourage out-of-office preventative care. Chronic care management has come to be an umbrella term of care delivered under CPT 99490, which reimburses healthcare providers for at “non-face-to-face” services delivered to qualifying patients.

CPT code 99490 was established in January 2015. In its first year, a mere 100,000 claims were made under CPT code 99490, surprising in light of the extent of the problem. To expand access, beginning January 1, 2016, CMS allowed Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) to receive an additional payment from CMS for the costs of services that are not already captured, including chronic care management, to Medicare beneficiaries.

The CMS chronic care management reimbursement code includes reimbursement for at least 20 minutes per month of out of office services provided by a physician or “other qualified healthcare professionals” to qualified patients. To qualify under code 99490, a patient must have two or more chronic conditions that are expected to last for at least 12 months and are terminal in nature.

The CMS code 99490 recognizes that technology now makes it possible for healthcare providers, caregivers, and patients to communicate effectively without requiring an office visit. In addition to the promise of more proactive preventative care, the code opens the door for new sources of income for medical practices. Time on the phone by non-physicians can be billed, as can video or other remote communications. Only clinical staff–certified nurse midwives, clinical nurse specialists, nurse practitioners, and physician assistants–are allowed to perform chronic care management services, but they may do so under the general (rather than direct) supervision of the practitioner.

As one might imagine, there are multiple requirements that come with offering and being reimbursed for chronic care management services. There are patient agreement requirements, technology requirements for access to care (care must be available 24×7), scope of services requirements, data recording requirements–to name a few.

Chronic care management is in its infancy. Adoption rates are growing and medical practices and entrepreneurs and looking for ways to streamline the delivery of services, lower costs, and increase profits. Companies are sprouting up to offer pre-packaged, cloud-based chronic care management platforms that take care of all the technical data reporting and privacy requirements, for example. Others business are now available to consult with practices and train staff to help them implement chronic care management and to deliver it efficiently. Services like call centers are also emerging to provide the required 24×7 support.

The promise of chronic care management is to help patients manage their conditions more independently and at less expense–preventing hospital admissions, emergency room visits, and even office visits that are straining the healthcare system. The goals are to improve the quality of life for patients with chronic care, improve the quality of care by delivering it where and when patients need it, and to lower the cost of care, all that once.