Checklist for Developing a Chronic Care Management Program

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by Adam Paul

Considering establishing chronic care management (CCM) program? Read on to gain a better understanding of CCM as a concept, the value of chronic care management and the steps you take that will better ensure you develop a strong CCM program that meets your patients' and organization's short- and long-term needs.  

Chronic Care Management Defined 

Chronic care management (CCM) is a care management service that provides continuous, wrap-around care and support for patients with two or more chronic conditions. Under the provision of CCM services, a physician and qualified care team can bill for the time spent managing the patients’ conditions, including formulating a comprehensive care plan; interactive, remote communication and management; medication management; and coordination of care between care providers.  

Why Organizations Need a Chronic Care Management Program 

Chronic care management helps compensate an organization for the care provided to patients outside of the normal confines of regular office visits. On average, Medicare reimburses about $120 per calendar month per patient for the provision of non-complex CCM services, making the service both an effective care modality for your most vulnerable patients and a consistent, high-revenue-generating service for the providing organization. It's no surprise to see Medicare "going all-in" on CCM. 

Checklist for Developing Your Chronic Care Management Program 

Use this checklist to help ensure your chronic care management program addresses the key facets required for establishing, growing, and billing CCM. 

Identify Your Goals and Cohort (identify patients and their chronic conditions) 

Identify the number and type of patients your CCM care team is prepared to manage. Answer these questions: 

  • How many patients can the care team manage effectively?  

  • Do you intend to incorporate any remote patient monitoring? If so, what kind of technology will need to be put in place? 

  • Which chronic conditions are most reflected in your patient population? 

  • Which of those chronic conditions will your care team most effectively manage? 

  • Which of those conditions pose the most mitigable risk to your patients? 

  • Determine whether your program will focus on only high-risk patients, or will it expand to medium- or even low-risk patients.  

  • Will your program include patients with all comorbidities or only select conditions?  

  • Determine if/what acute events might trigger patient enrollment into monitoring.  

Sketch out your care protocols 

  • Given the disease states and patient cohorts, you are trying to target, plan out your care protocol and draft corresponding patient care plans. 
  • Determine what “stop-light” protocols you want in place based on a chronic condition. These will be care plan triggers that initiate an immediate notification to the practitioner. 
  • Draft out the major areas of your care plans: 
  • Patient goals (e.g., diet, exercise) 
  • Common barriers the patient might run into (e.g., social determinants of health
  • Medication management (if applicable) 
  • Social and community resources 
  • Determine if/which metrics need to be documented depending on the chronic disease(s) being managed. Examples of specific metrics include: 
  • Pain level 
  • Blood pressure 
  • Blood glucose level 
  • Body mass index 
  • Resting heart rate 

Ensure your cohort and protocols meet the Medicare requirements for CCM 

  • Your cohort patients must have two or more chronic conditions expected to last at least 12 months or until death.  
  • Those chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.  

Establishing the Internal Framework (ensuring your organization is ready to deliver chronic care management services) 

Ensure you can meet Medicare’s requirements for providing CCM 

  • Offer 24/7 access to physicians or other qualified healthcare team members. 
  • This can be accomplished through the telephone or telehealth modalities such as a secure internet portal or email.  
  • Use a certified EHR system defined by “meaningful use” guidelines. 

Designate care team member(s) 

  • Designate or hire qualified staffing who can dedicate the time needed for CCM patient care activities, such as appointments, coordination of care, and regular check-ins. 

Create technology infrastructure 

  • Develop appropriate CCM templates and time-tracking capabilities within an existing EMR or partner with a technology platform (e.g., Prevounce) that will accurately track time and help organize documentation related to all CCM patient activities. 

Develop ability to identify qualified CCM patients 

  • Establish processes by which you can identify patients who qualify for care management services (e.g., reporting system or service that can extract data on qualified patients based on diagnosis). Note: If you need assistance with establishing such processes and are a Prevounce client, speak with your account representative.  

Create standardized medical record 

  • Develop and use a standardized medical record that collects and maintains required data and information for the charting and billing of CCM services. 

Providing Chronic Care Management (establishing your CCM workflow) 

Notify patients 

  • Once an eligible patient has been identified, you must inform them of the availability of CCM services and any co-insurance/out-of-pocket costs associated with participation.  

Enroll and obtain informed consent 

  • Patients must consent that they wish to participate in CCM services. Consent can be verbal or in writing but must be documented in the medical record. 

Provide care management 

  • Schedule when and how patient outreach will occur. This should be individualized and based on each patient’s needs, per physician orders. 
  • Determine which communication modalities, or combination of modalities, you intend to use for care management purposes (e.g., phone, video chat, secure email). 
  • Plan and schedule ongoing care plan updates and patient check-ins. 
  • Record all time spent on managing the patient's care plan, reviewing diagnostics and vital measurements, coordinating care, discussing the patient’s social determinants of health, and any other patient-related communications or activities.  

Produce care plan 

  • Create and document the patient’s care plan, ensuring they receive a copy. 

Maintain documentation 

  • Documentation must be maintained within the patient’s medical record that CCM was explained in full, with notation of whether the patient accepted or declined to participate in CCM services. 

Getting Paid (meet the billing requirements for chronic care management) 

These are the six chronic care management codes you will use to bill CCM services: 

  • CPT 99490 — Used for the first 20 minutes of a calendar month for the purpose of chronic care management using clinical staff time and directed by a physician or other qualified health professional.
  • CPT 99491 For CCM services that total at least 30 minutes per calendar month. To use this code, the services must have been provided by a physician or other qualified healthcare professional.
  • CPT 99439 This code is used in addition to 99490 capture additional care that exceeds the 20-minute time allotment. 99439 is used for every additional 20-minute increment of service time and may be used up to two times for a maximum of 60 minutes total.
  • CPT 99437 This code is used in addition to 99491 capture additional care that exceeds the 30-minute time allotment. 99437 is used for an additional 30-minute increment of service time and may be used once for a maximum of 60 minutes total.
  • CPT 99487 This code is for complex CCM services that total at least 60 minutes of clinical staff time per calendar month. This time must be directed by a physician or other qualified healthcare professional. Complex CCM patients are those who require moderate- to high-complexity medical decision-making
  • CPT 99489 This code is used for an additional 30-minute increment of complex CCM provided to the patient in a calendar month.  

To learn more about these CPT codes, their rules, and other codes frequently associated with those for CCM, read this article

Want more advice on building a successful CCM program? Download our guide.


Need Help Establishing a CCM Program? 

Reach out the team at Prevounce! Prevounce CCM removes the complexities and confusion surrounding chronic care management and reimbursement through personalized, compliant solutions that fit seamlessly into any organization's workflow. To learn more, schedule a demo

CPT Copyright 2022 American Medical Association. All rights reserved. 
CPT® is a registered trademark of the American Medical Association. 

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