CHRONIC CARE MANAGEMENT. A Guide to Medicare s New Move Toward Patient-Centric Care

CHRONIC CARE MANAGEMENT A Guide to Medicare s New Move Toward Patient-Centric Care

The future of healthcare is here; Medicare has begun to shift away from fee-forservice care and move toward value based care. CMS approved monthly Chronic Care Management (CCM) reimbursements that began on January 1, 2015. The goal was to improve health outcomes and satisfaction for patients, reduce duplicate testing that often clogs up the healthcare system, and reduce unnecessary healthcare costs. Adoption has been somewhat slow, but that s about to change for the better. 10,000 baby boomers will turn 65 each day through 2029 and providers will begin to experience an ever growing patient base that is prone to developing multiple chronic illnesses. Caring for this massive group of people will become top priority for providers and for Medicare. Since providers are already managing Medicare patients with two or more chronic conditions, integrating these Care Plans into a robust CCM program is the next logical step. Improve the health of patients and generate new recurring revenue

CHRONIC CARE MANAGEMENT A Guide to Medicare s New Move Toward Patient-Centric Care CHRONIC CARE MANAGEMENT (CCM) 4 Overview 4 The Medicare Objective 5 CPT Code 99490 6 CMS REQUIREMENTS 7 Eligible Providers 8 Provider Requirements 9 The Care Plan 10 Electronic Health Records (EHR) 11 Billing 12 Navigating the TCM and CCM overlap 13 Coordination of Care 13 ABOUT CARESYNC 13 CareSync History 14 The CareSync Solution 15 Conclusion 15 Partnering with CareSync 16 ADDITIONAL RESOURCES 16

CHRONIC CARE MANAGEMENT (CCM) OVERVIEW As of January 1, 2015, the Center for Medicare and Medicaid Services (CMS) recognize care management as a critical component of primary care that contributes to better health outcomes and care for individuals, as well as reduced spending. Chronic Care Management (CCM) is defined as patients having: Two or more chronic conditions expected to last at least 12 months, or until the death of the patient Chronic conditions that place the patient at significant risk of death, or acute exacerbation/ decompensation Below are examples of common chronic conditions among Medicare patients: 57% 47% 15% 15% 16% 17% 18% 23% 28% 29% 30% COMMON CHRONIC CONDITIONS AMONG MEDICARE PATIENTS Acquired Hypothyroidism Heart Failure Depression Chronic Kidney Disease Cataract Anemia Diabetes Ischemic Heart Disease Rheumatoid Arthritis/ Osteoarthritis Hiperlipidemia Hypertension Chronic diseases are not limited by CMS, as they have left the ruling open to discernment by the provider. CMS maintains a Chronic Condition Warehouse (CCW) 1 with 22 chronic conditions listed to provide beneficiary, claims, and assessment data; though it is not an exclusive list. 1 https://www.ccwdata.org/web/guest/medicare-charts/medicare-chronic-condition-charts

7 / 10 Seven out of ten causes of death in 2010 were chronic illnesses. 85% Eighty five percent of healthcare spend goes to the treatment of chronic illness. Two out of three of Medicare dollars are spent on patients with 5+ chronic conditions. In the United States THE MEDICARE OBJECTIVE Chronic diseases 2 and conditions, including heart disease, diabetes, COPD and obesity, are among the most common, expensive, and preventable health problems in the United States. In America, 117 million adults have at least two or more chronic conditions that require CCM. According to the Center for Disease Control (CDC), research consistently shows that effective chronic care management reduces the costs of care for chronic disease patients while improving their overall health. Historically, providers have not been reimbursed for the between-visit care they provide. Chronic disease patients are often left to coordinate between-visit care for themselves; creating huge gaps in patient-provider communication that results in fragmented health data, duplicated tests, increased healthcare expenses, and a higher likelihood of poor health outcomes. 2 http://www.cdc.gov/chronicdisease/overview/ 2/3

The Provider Opportunity CMS recognizes the importance of taking care of the patient all of the time, not just at the point of care, and the impact that it has on healthcare expenses and patient outcomes. CMS is now paying providers monthly reimbursements for patient-centered care coordination services for individuals to have better healthcare and to reduce unnecessary healthcare spending. CPT CODE 99490 The Current Procedural Technology (CPT) 3 Code 99490 pays approximately $41 per patient per month 4 to providers who deliver 20+ minutes of non face-to-face chronic care coordination to eligible Medicare beneficiaries with 2 or more chronic conditions. These services may be fulfilled by the provider or performed by a subcontractor. Code 99490 pays approximately $41 per patient per month The Final Rule of the 2015 Medicare Physician Fee Schedule included the new CPT Code 99490, defined as: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, with the following required elements; multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive Care Plan established, implemented, revised, or monitored. (CMS Final Rule, October 31, 2014) 3 CPT is registered trademark of the American Medical Association 4 $41 per month is the national average. Actual amounts will vary by region

CMS REQUIREMENTS CMS has listed the following specific requirements in order for providers to bill CPT 99490: A comprehensive, patient-centered Health Summary and Care Plan that includes all current records from all the patient s providers 24/7 access to clinical staff to address urgent chronic care needs Continuity of care through access to an established care team for successive routine appointments Ongoing care management for all chronic conditions, including medication reconciliation and the regular assessment of a patient s medical, functional, and psychosocial needs Management of care transitions between and among all providers and settings using electronic transmission of information Coordination with home and community-based clinical service providers Patient and caregiver access, with enhanced opportunities for all relevant caregivers to communicate about the patient s care

ELIGIBLE PROVIDERS The intent of CMS is to have primary care coordinate patient care, however, the code allows for most providers, including specialists, to perform the services. While the billing provider must oversee the CCM services, they are not required to be present for the work to be done. Physicians, regardless of specialty, advanced practice registered nurses, physician s assistants, clinical nurse specialists, and certified nurse midwives are all eligible to bill Medicare for CCM. Non-physician and limited-license practitioners, such as clinical psychologists and social workers, are not eligible to bill for CCM. The code allows for most providers to perform the services New Providers Eligible in 2016 According to CMS, Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) now qualify to bill for CCM at the national average non-facility rate. A FQHC or RHC must meet the same requirements as other providers to bill for CCM, including the requirements to use EHR. For RHCs and FQHCs any non-face-to-face care management services must be furnished by clinical staff under direct supervision. This means that they must provide these services while present in the same office as the supervising practitioner who is immediately available to provide assistance. FQHCs are providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants as well

as the homeless. FQHC Program s main purpose is to supplement the provision of primary care services in underserved urban and rural communities. To qualify as a RHC, a clinic must be located in a non-urbanized area, as defined by the United States Census Bureau; and an area currently designated by the Health Resources and Services Administration as one of a Federally designated or certified shortage areas. Each patient may be billed only once per month PROVIDER REQUIREMENTS In order to bill for CCM, providers must get the patient s written consent during a comprehensive or an Annual Wellness Visit (AWV), confirming that the following has been explained to the beneficiary: An overview of the CCM services How the CCM service may be accessed That information will be shared among all the patient s providers That the patient can terminate the CCM service by revoking consent That the patient will be responsible for any associated co-payment or deductibles That only one provider can provide CCM services at a time Once the consent form is signed, a copy must be stored in the patient s medical record. If a patient does choose to revoke consent, providers may not bill for CCM after the month the revocation was made. If the 20+ minutes of CCM has already been completed, providers may bill for that month.

THE CARE PLAN At the core of the code, providers must maintain a regularly updated, electronic Care Plan that is based on an assessment of the patient s needs. The plan should include all of the patient s healthcare providers, family, caregivers, all health conditions (not just those considered chronic), and be aligned with the patient s choices and values. CMS has provided the following items as recommendations to be included in the patient s comprehensive Care Plan: Comprehensive problem list including expected outcome and prognosis with measurable treatment goals Symptom management and planned interventions Accessible community and social services Plan for care coordination among all providers Medication management, including current medication list, allergies, reconciliation, and oversight of patient selfmanagement Designated person responsible for each intervention Any requirements for regular review/revision

The Care Plan must be created using some form of electronic technology ELECTRONIC HEALTH RECORDS (EHR) Any provider billing for CCM is required to use an EHR that satisfies the 2011 or 2014 criteria of the EHR Incentive Program. CMS requires that the Care Plan must be created using some form of electronic technology, but recognizes that current, provider-centric EHR technology is limited in its scope to support electronic Care Plans. CMS further stipulates that providers must have flexibility to use a wide range of tools and services beyond EHR technology now available in the market to support electronic care planning. There are three requirements regarding electronic access to the patient s Care Plan: All care team members must have 24/7 electronic access to the Care Plan. The billing provider must electronically share Care Plan information as appropriate with other providers who care for the patient. Faxing does not meet this requirement. The billing provider must give a paper or electronic copy of the Care Plan to the patient. The CMS scope of service for EHR includes structured recordings of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record.

BILLING In order to receive reimbursements from Medicare or Medicare Advantage plans, providers must meet several new technology and services requirements for creating and sharing comprehensive Care Plans with the patient and all of the patients other providers. Providers must offer 24/7 access to a member of the care team to address urgent chronic care needs and facilitate care coordination in order to bill for CCM. This includes successive routine appointments and enhanced opportunities for patient/caregiver-provider communication, such as direct messaging or in-app communication. Additionally, providers furnishing CCM are required to coordinate referrals with other providers, as well as share up-to-date information electronically with all of the the providers on a patient s care team. Faxing this information does not meet this requirement. Providers must meet several new technology and services requirements for creating and sharing comprehensive Care Plans

NAVIGATING THE TCM AND CCM OVERLAP Billing providers must facilitate all transitions of care, including the follow-up with a patient after a visit to the Emergency Room and post-discharge Transitional Care Management (TCM) services. You are unable to bill for CCM and TCM during the same 30-day period. TCM Includes: Medication reconciliation Communication with patient or caregiver Access to care and services needed by the patient or their family Review need for follow-up tests and treatments Assist in scheduling appointments Billing Example: September 1 st - September 14 th 20 minutes met Patient admitted - September 15 th Patient discharged - September 16 th September 16 th - October 15 th October 16 th - October 31 st 20 minutes met COORDINATION OF CARE Providers must have the ability to coordinate care with home and community-based providers, including home health, hospice, nutrition services, outpatient therapies, and transportation services. The conversation and exam to commence CCM must be documented in the EHR. ABOUT CARESYNC

Care coordination technology and services were purposefully created by CareSync in 2011 with the intent to proactively manage a patient s chronic conditions rather than simply treat illness and diseases. It facilitates better health and patient care while avoiding the need for repetitive or costly services. CARESYNC HISTORY 2000s Our founders built several EMRs including the first cloud based EMR 2011 CareSync was established to help people coordinate their care for improved health outcomes 2013 Well before CPT code 99490, CareSync launched nursing services to help people build and follow a comprehensive Care Plan 2015 CMS Launched CPT Code 99490 CareSync has been doing it since 2011 Many healthcare companies are pivoting to offer CCM CARESYNC TODAY The leading provider of CCM solutions to providers and their patients in the United States

THE CARESYNC SOLUTION CareSync is a patient-centered solution that combines industry-leading technology with 24/7 nursing and care coordination services. CareSync facilitates care coordination among patients, family, caregivers, and all providers 24/7. CareSync provides full-service Chronic Care Management services as well as a software-only option, allowing practices of any size to easily meet the challenging requirements for CPT code 99490. Chronic Care Management creates new opportunities for added revenue and enhanced patient care by offering patients and their families the most comprehensive care coordination solution available 24/7. Many providers throughout the United States are looking for ways to offer this proven and effective benefit to their patients, while adding a monthly recurring revenue to their practice that adds up to significant annual earnings. The strict billing requirements of the CMS Chronic Care Management initiative are at the very core of what CareSync has been providing for years. The unique combination of industry-leading technology and care coordination services creates a turnkey chronic care management solution that provides CCM for practices. CONCLUSION As Medicare moves into supporting CCM for patients with 2 or more chronic conditions, better quality of care, and reduced healthcare spending; providers need to be ready to adapt and embrace the multiple opportunities that CPT Code 99490 brings. While the requirements and regulations of CCM can be challenging to understand or implement, CareSync acts as a partner to a physician s practice making transitioning easy, quick, and with little disruption to daily workflows. CareSync simplifies the CCM process to help healthcare providers significantly enhance their revenue stream while providing complete care solutions to patients, caregivers, and family members. That s a big win for everyone. CareSync offers a patientcentered solution that combines technology with services

PARTNERING WITH CARESYNC Getting started with CareSync is easy. CareSync ensures that providers benefit from this revenuegenerating opportunity easily while providing stellar between-visit care to eligible patients. It is designed to work with a provider s current EHR system. A dedicated Implementation Manager will help guide the practice through a simple set up. CareSync takes the burden off providers and staff Works with existing workflows and EHR technology No upfront cost to providers or physicians CCM Resources when providers need it STAT CareSync acts as a true extension of a practice by providing its people as provider and patient resources 24/7. CareSync equips providers with best practices and proven tools to enroll eligible patients. Implementation is quick and easy. Dedicated Account Managers guide providers through the CCM process every step of the way. CareSync is designed to work with the existing technology in practices making it easy to use. CareSync acts as a true extension of a practice ADDITIONAL RESOURCES View a CCM Webinar given by CareSync Director of National Markets, James Grant at: http://bit.ly/1mhlvvv Sign up for a live webinar: info.caresync.com/webinars Ready to learn why CareSync is the leader in Chronic Care Management? CALL US TODAY at E-MAIL US at VISIT US at 800-587-5227 sales@caresync.com www.caresync.com CareSync January 2016. All rights Reserved. 2016JUN28