Chronic Care Management helps people with ongoing health problems. Chronic illnesses cause most healthcare spending in the United States. They are also one of the top reasons for death.. Healthcare providers are using Chronic Care Management (CCM) programs to manage this issue.
The Centers for Medicare & Medicaid Services (CMS) defines CCM as services for people with two or more long-term health problems. These services happen outside regular doctor visits. CMS says CCM is an important part of care for Medicare patients. It supports people who live with diseases such as heart failure and diabetes. CCM helps them take care of their health at home. It also lowers the need for emergency care.
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Understanding Chronic Care Management (CCM)
Medicare started chronic care management to support people with more than one long-term illness. These services happen between normal office visits. Medicare Part B pays providers each month to give CCM services. Patients must have at least two health problems. These problems must be expected to last for one year or longer.
Key services include:
- Making and updating an electronic care plan
- Managing medications
- Coordinating care with other doctors and services
- Giving patients 24/7 access to help
Doctors direct these activities. The care team performs most of the work. This team includes nurses and care managers. CMS has created billing codes. These codes help providers get paid for this time. These billing codes also support remote care management. They help track patient care more clearly.
Why CCM Matters for Patients and Providers?
Chronic Care Management helps people stay healthier. A NIH report found fewer hospital visits among CCM patients. These patients had 61% fewer hospital stays. They also had 55% fewer emergency visits. Preventive care visits went up by about 8%. CCM helps patients stay in touch with their care team. This helps avoid problems.
CCM also helps healthcare providers. Medicare pays them monthly. This payment helps cover the extra time spent helping patients. CCM gives patients more support between visits. It also adds new income for clinics. This program improves health. It also supports the people who give care.
Engaging Patients and Caregivers
Chronic care management works better when patients help with their care. The care team helps people choose goals they understand. A person with diabetes may learn how to check blood sugar. A person with lung disease may learn how to use an inhaler.
The medical office team checks in with patients often. This can be through calls, messages, or video chats. Caregivers also help with medicines and appointments. Patients who are involved are more likely to take their medicine. They are more likely to go to appointments. They are also more likely to notice early signs of health issues.
Using Technology and Data in CCM
Virtual assistants for chronic care management use tools to help with patient care. Electronic health records help care teams keep plans current. Portals help patients get reminders. They also allow patients to send questions.
Remote devices help track health. These devices send data to the care team. CMS says checking remote care management data counts toward CCM time. Providers can include these tools in their monthly tasks. This helps avoid missing any patients. These tools help clinics follow many patients at once.
Key Components of Effective CCM
Chronic care management includes several steps that must be followed.
- Patient Identification and Enrollment: Start by finding Medicare Part B patients. These patients must have at least two long-term conditions. Get their consent to be part of the program. Consent can be given in writing or orally.
- Care Plans: Each patient needs an electronic care plan. This plan should list their health problems, treatments, goals, and medicines. CMS requires this plan to stay current. It must be reviewed often.
- Care Coordination: Clinics must help patients move between care providers. This includes speaking with other doctors and services. Patient information should be shared quickly. This helps avoid delays or mistakes.
- Team-Based Care: Each patient should have a main contact person. This person helps the patient at any time. CMS says care teams must be available 24 hours a day. They must also be available 7 days a week.
- Patient Education: Patients and caregivers need to learn how to manage their health. They should understand their medicine. They should also know how to plan their care. This helps patients take part in health decisions.
- Data Tracking and Review: Care teams must check on each patient once a month. They need to review vital signs, test results, and medicines. The care plan should be updated. All steps must be written down each month.
- Technology and Tools: Electronic health records and portals help teams stay organized. Tools such as remote blood pressure monitors send health data to care teams. These support virtual chronic care management.
Navigating CMS Guidelines and Chronic Care Management Codes
CMS has rules for billing Chronic care management. Providers must follow these rules each month. CPT code 99490 is for 20 minutes of staff time. Code 99439 adds more time in 20-minute parts. Code 99487 is for 60 minutes of complex care.
Code 99489 adds 30 more minutes to complex care. Code 99491 is for 30 minutes from a doctor or nurse. Code 99437 adds another 30 minutes of provider time. You cannot bill both regular and complex care in the same month. You also cannot count the same time for two services. Providers must update care plans monthly. They must log the time they spend. They must follow all billing steps. Doing this helps providers bill the correct chronic care management codes.
Getting Started with CCM in Your Practice
Start chronic care management by finding patients. These are often people who go to the hospital. They may also see many doctors. Use reports or ask staff to identify these people.
Meet with each patient or set up a video call. Explain the program. Ask for consent. Create a care plan. Assign a staff member to check on each patient monthly. This person can remind patients to take medicine. They can help schedule tests or visits. A chronic care management company may provide software to track time and steps. Train your staff. Teach them how to use the billing codes.
Virtual Chronic Care: Stay Updated on Chronic Patients’
Chronic care management helps clinics support patients with long-term health issues. It helps patients stay out of the hospital. It helps them follow their care plans. It also lets clinics get paid for their care work between visits.
Care teams must follow Medicare’s coding rules. They must update care plans and stay in touch with patients. They should use tools to track progress. When done well, CCM helps people get the care they need. Clinics and hospitals can support people who live with long-term health needs.
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