Breaking down the cost of chronic disease management for your practice
By Ryan Atwood
Vice President of Payer Relations and Regulatory Compliance
Over 133 million Americans live with a chronic disease, and that number is steadily increasing. The Centers for Medicare and Medicaid Services (CMS) has increased reimbursements this year to incentivize physicians to adopt chronic care management at their practices to help patients manage these diseases in their homes to prevent their health from declining. With the medical community focusing on meeting patients where they are, extending care beyond the clinic, and addressing social determinants of health, the increased reimbursement is a logical move from CMS. This effort to prevent patients’ conditions from deteriorating can reduce hospital admissions - which is especially vital amidst the ongoing physician shortage - and ultimately lead to cost savings for patients, Medicare and other payers.
A Closer Look at CPT Code 99490
This code is one of the foundational Current Procedural Terminology codes for CCM. It describes a 20-minute service provided by clinical staff to coordinate care across providers and support patient accountability. Patients must have two or more chronic conditions that they are expected to have for a minimum of 12 months to qualify for 99490. To qualify, the patient must receive at least 20 minutes of monthly CCM services from clinical staff.
Only certain physicians and non-physician practitioners can bill for chronic care management services. These include:
- Certified Nurse Midwives
- Clinical Nurse Specialists
- Nurse Practitioners
- Physician Assistants
CCM reimbursements are limited to one physician or healthcare provider leading a patient care management plan in a given calendar month. To enroll a patient for CCM and submit a bill using these CPT codes, healthcare providers need documented consent from the patients, along with a comprehensive care plan. Consent forms also require the patient’s agreement to pay their copay and deductibles for care services. Once enrolled, clinical staff must then deliver 20 minutes of care each month to the patient focused on achieving the health goals detailed in the care plan. Physicians also need to make the care plan available to all the patient’s care providers.
CCM Code and Reimbursement Breakdown
As we discussed on a recent webinar, physicians are still making sense of what the new CCM reimbursements look like and what they mean for their practice. CMS introduced Chronic Care Management (CPT 99490) in 2015 for traditional Medicare patients with multiple (two or more) chronic conditions and has removed barriers to participation every subsequent year. CMS has doubled down on the efforts to engage patients in between visits, raising reimbursement in 2022 by 51% compared to 2021, up to a national average of $64 per patient per month (CPT 99490) and up to a national payment rate of $79.25 per patient per month for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC) (G0511). The move by CMS adds value not only to traditional fee-for-service and FQHC structures but to value-based care organizations. In fee-for-service arrangements, chronic disease management programs provide an opportunity to diversify revenue while offering a service that improves patient outcomes, a better continuity of care - outcomes that are also important for value-based care.
Tailoring Care with Engooden
At Engooden, we believe attaching comprehensive CCM programs to primary care to manage patients between visits proactively is the only way to make value-based care successful. We make this a reality using our proprietary technology with a services wrapper to implement customizable chronic disease management programs for both fee-for-service populations and patients enrolled in value-based care contracts, ACOs, and commercial plans. We primarily serve rising-risk patients – the 45% of people most frustrated with the healthcare system and most likely to become high-risk.
Engooden care navigators are highly trained, caring, and empathetic individuals who help patients manage their health between physicians’ visits. Unlike most CCM vendors, who meet the standard of 20 minutes of working the patient care plan, our care navigators spend at least 20 minutes every month (and often more) speaking directly to patients, getting to know more about them and their conditions. This relationship drives better adherence to a patient’s care plan, leading to healthier outcomes. With our model, physicians can scale their chronic care program to the majority of mid-risk and rising-risk patients in a cost-effective way.
We invite you to view our “Doubling Down on Chronic Care Management" webinar to learn more about the CMS reimbursement increase and get insight on why now is the prime time to invest in chronic disease management. If you have any questions as you view the content or are interested in learning more about working with Engooden Health, please reach out to us at firstname.lastname@example.org.