What Is Chronic Care Management: Key Considerations

In today's evolving healthcare landscape, chronic care management (CCM) is crucial for meeting the complex needs of patients with long-term conditions. According to the Centers for Disease Control and Prevention (CDC), approximately 120 million adults in the U.S., representing 60%, grapple with at least one chronic health issue. Additionally, 40% manage two or more conditions concurrently, and nearly half of adults aged 75 and older contend with three or more chronic conditions. These are staggering statistics that we cannot ignore.

Chronic diseases are a leading cause of death and disability in the United States, significantly impacting healthcare costs and patient well-being. This article by our team at APEX Health Services explores the vital role of chronic disease management, highlighting its benefits and how it is transforming healthcare delivery.

What Is Chronic Care?

Chronic care management is a vital healthcare service designed to support patients with ongoing medical conditions that need long-term management. Accredited by the Centers for Medicare & Medicaid Services (CMS), CCM provides comprehensive care coordination that extends beyond conventional office-based healthcare services. It’s a proactive approach that’s essential for individuals facing chronic illnesses ranging from arthritis and heart disease to diabetes and cancer. Chronic care management has been a win-win for patients and practitioners — and the healthcare system as a whole — for nearly 10 years now.

Qualifying Conditions

A chronic condition typically:

• Persists for a year or longer.
• Limits an individual's ability to perform daily self-care tasks independently.
• Requires continuous medical attention.

To qualify for Chronic Care Management under Medicare, patients must have two or more chronic ailments expected to endure for at least 12 months. These ailments commonly include:

• Alzheimer’s disease and related dementias
• Arthritis (both osteoarthritis and rheumatoid arthritis)
• Asthma
• Cancer
• Cardiovascular diseases (such as hypertension and heart failure)
• Chronic obstructive pulmonary disease (COPD)
• Depression
• Diabetes
• Infectious diseases like HIV/AIDS
• Kidney disease
• Osteoporosis
• Stroke

What's Included in CCM Services?

Under Medicare Part B, CCM services cover crucial aspects of non-face-to-face care coordination for patients with complex chronic conditions including:

• Ongoing care coordination: Facilitating seamless communication and collaboration among healthcare providers to guarantee holistic care.
• Medication management and reminders: Monitoring and supporting medication adherence to improve treatment outcomes.
• Assistance with healthcare appointments: Helping patients navigate and attend needed medical appointments.
• Support for activities of daily living (ADL): Assisting with daily tasks to maintain independence and quality of life.

Additionally, chronic care management includes services such as:

• Managing prescription refills: Arranging timely medication refills and management.
• Monitoring and addressing symptoms: Proactively managing symptoms to prevent complications.
• Providing health education: Providing patients with resources to manage their health conditions better.
• Offering preventive health counseling: Guidance on preventive measures to mitigate health risks.
• Connecting to community resources: Referring patients to local resources and support services.
• Implementing fall risk interventions: Strategies to reduce the risk of falls, especially for elderly patients.
• Coordinating social support services: Facilitating access to social services for overall well-being.

Advantages of Chronic Care Management Services

CCM services offer a range of benefits that enhance patient care and practice outcomes:

• Improved health outcomes: CCM provides structured care plans and regular check-ins to effectively manage chronic conditions to reduce symptom severity and slow disease progression.
• Increased revenue: Participating in CCM offers new revenue streams through Medicare reimbursements, focusing on quality care delivery over volume.
• Fewer hospitalizations: CCM reduces hospital admissions and emergency room visits by proactively managing chronic conditions.
• Enhanced treatment adherence: Patients benefit from personalized support, improving adherence to treatment plans and reducing complications.
• Patient engagement: CCM empowers patients with education and tools for self-management to foster active participation in their health.
• Improved access to care: Accessible telephonic services and 24/7 support guarantee timely interventions and reduce barriers to care.

Who Is Qualified to Deliver Chronic Care Management?

CCM is a reimbursable service under Medicare and it requires specific qualifications for providers to bill for these services monthly. Medicare mandates that all CCM activities must be overseen by one of the following qualified professionals:

• Physicians
• Clinical nurse specialists (CNS)
• Nurse practitioners (NP)
• Physician assistants (PA)
• Certified nurse-midwives (CNM)

CCM services are available not only in physician offices but also in Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Critical Access Hospitals (CAHs). These healthcare settings make CCM services more available to diverse communities and populations.

Organizations that employ only registered nurses cannot bill Medicare for CCM services unless supervised by a qualified provider. The supervisor doesn’t need to be physically present during the service but must provide general oversight and guidance.

Providers delivering CCM services must be part of the clinical care team, not administrative staff. State regulations may also impose additional criteria beyond Medicare's requirements for delivering CCM services.

How Does CCM Get Recorded in an Electronic Health Record (EHR)?

CCM documentation in an EHR is crucial for accurate billing and compliance with CMS requirements. A certified EHR needs to facilitate the structured recording of patient health information. Here are some key elements to document:

• Patient consent
• A comprehensive care plan encompassing a problem list
• Measurable treatment goals
• Planned interventions
• Medication management
• Coordination with external resources
• At least 20 minutes of non-face-to-face clinical staff time per month

Practices utilize EHR systems with integrated CCM documentation features or specialized software for tracking and ensuring all billing criteria are met. Some software also supports reminders to providers, patients, and caregivers, while some practices opt for manual tracking methods.

Do Patients Have to Pay for Chronic Care Management?

Chronic care management services are covered under Medicare Part B, with Medicare typically covering 80% of the cost. In other words, Medicare beneficiaries are responsible for the remaining 20% of the bill for CCM services. If you have Medigap or dual coverage with Medicaid, your copay may be covered by these additional insurance plans. In such cases, the 20% copay would be billed to the secondary insurance provider.