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New CMS Initiative Can Generate Revenue for Physicians


The 2015 Medicare Physician Fee Schedule (PFS) will pay for non-face-to-face services for CPT Code 99490 — Chronic Care Management (CCM), reimbursing practices on an average of $42 per patient, per month. Of all the governmental mandates that have come along — this is a good one. It incentivizes physicians to extend their care management and care coordination services to their patients who need it the most, and it will improve outcomes for critically-ill patients. 

CMS has recognized that in the U.S. seven of the top ten causes of death are from chronic illnesses, with 85 percent of healthcare costs going to treat those diseases and two-thirds of Medicare dollars being spent on patients with five or more of these chronic conditions. 

In 2010, Medicare spending totaled over $300 billion and increased significantly as the rate of chronic conditions increased. In that year, beneficiaries with two or more chronic conditions accounted for 98 percent of all Medicare hospital readmissions. As staggering as the readmissions number is, more daunting is the fact that CMS estimates that $17 billion of the $26 billion spent on readmissions were potentially avoidable.

The most common chronic conditions among Medicare beneficiaries in 2010 were high blood pressure, high cholesterol, heart disease, arthritis and diabetes.

Chronic diseases such as diabetes, cancer and asthma are the most common, costly and deadly of all health problems – yet also the most preventable, according to the Centers for Disease Control and Prevention (CDC).

CMS has started paying monthly reimbursements for Chronic Care Management services to providers who deliver 20 plus minutes of non-face-to-face chronic care coordination to eligible Medicare beneficiaries with two or more chronic conditions.

These services can be fulfilled by the provider or performed by a subcontractor. This is a critical element of the CMS initiative.

Traditionally, physicians have not had the staff bandwidth to support intensive Chronic Care Management; however, this initiative allows doctors to outsource much of the hands-on daily care coordination to healthcare organizations who are staffed with experienced care management professionals. The billing physicians are responsible for creating their critically-ill patients’ care plans and directing the efforts of their professional outsourced staff.

Medicare has traditionally only paid providers for care management services as part of face-to-face office visits. The new CCM payment applies to both Medicare and Medicare Advantage patients.

Patients are still responsible for a 20 percent copayment, and documentation of the CCM services is required. However, costs should not be an issue because research shows that only one in ten beneficiaries rely solely on Medicare for their healthcare coverage. The rest have some form of supplemental coverage for medical expenses, so up to 90 percent of patients may not have to pay any out of pocket for their CCM.

The biggest change for this new initiative is the focus placed on patient collaboration and care coordination that takes place outside of office visits. Non-face-to-face service includes any time the provider spends on the patient’s care plan – anything from communicating with other health providers (outsourced care management staff) on behalf of the patient’s care management.

CMS allows physicians who bill for Code 99490 to delegate this non-face-to-face time, and provide only general supervision on the CCM work they do. This critical change allows physicians with smaller professional staffs to extend the care management of chronic diseases to their patients who need it the most, and at the same time create a new revenue stream.

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