Overview of the Medicare Chronic Care Management (CCM) program

CCM is a new program within Medicare (CMS) that contributes to better outcomes and higher satisfaction for patients. CMS recognizes that providing CCM services takes provider time and effort and has established a separate payment with new CPT billing codes for the additional time and resources our medical practice spends to provide the between-appointment help many of our Medicare and dual eligible (Medicare and Medicaid) patients need to stay on track with their treatments and care plan for better health.

CCM codes can be billed for services furnished to patients with two or more chronic conditions who are at significant risk of death, acute exacerbation or decompensation, or functional decline. Medicare patients at Nura all have chronic pain as their main problem and most have multiple other co-morbidities such as obesity, hypertension, diabetes, lung disease, and rheumatoid arthritis. CCM can help us deliver coordinated care to our patients that will improve their health, increase satisfaction with their care, and make care more person-centered.

What Is CCM?

At Nura, CCM is care coordination and case management that is outside of the regular pain clinic visits for patients with chronic pain and multiple (two or more) chronic conditions “expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline”. CCM can be delivered to people with many different types of health conditions but all CCM patients at Nura will have one health problem in common – chronic pain.

Medicare began paying for CCM services separately in 2015. Practitioners may now bill for CCM for a calendar month when at least 20 minutes of nonface-to-face clinical staff time, directed by a physician or other qualified health care professional, is spent on care coordination for a Medicare patient with multiple chronic conditions.

Why Is CCM Important?

Patients Benefit from CCM

• Our patients will gain a team of dedicated health care professionals who can help them plan and stay on track for better health. Services, such as monthly check-ins and ready access to our care team, improve patient care coordination, including improved communication and management of care transitions, referrals, and follow-ups.
• CCM patients will receive a comprehensive care plan. The care plan will help support disease control and health management goals, including physical, mental, cognitive, psychosocial, functional, and environmental factors. Patients may also receive a list of suggested resources and community services. Additionally, patients may be encouraged to keep track of referrals, community support, and educational information.
• Encouraging patients to use CCM will give them the support they need between visits. Having a regular touch point may help patients think about their health more and engage in their treatment plan, for example, by becoming more conscious of taking medications, managing fall risk, and other self-management tasks. Getting this help may also encourage patients to stay on track and improve adherence to their treatment plan. More frequent communication can also help make patients feel more connected to Nura and our pain clinic staff.
• Improve care coordination. Chronic care management can help improve care coordination and health outcomes and will give patients the support they need between visits to our pain clinic.
• Support patient compliance and help patients feel more connected. Some health care professionals have reported that making CCM services available to their patients has helped to improve their efficiency, improve patient satisfaction and compliance, and decrease hospitalization and emergency department visits.

 

Information retrieved from: https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CCM-Toolkit-Updated-Combined-508.pdf