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Powerpoint presentation

Chronic Care Management
Target Audience: Hospitals and Clinics

Chronic Care Management Session Presenter: Target audience: Evident and Healthland • Peggy Hansen, MSN, FNP Senior Consultant, TruBridge Recommended for: Clinic Directors

What is the Need?

What have we tried: Care Coordination – program focus on complex care, end-of-life care Case Management – focused on CHF, diabetes, drug compliance Disease Management -- trying to improve quality by managing disease indicators Health Promotion – Comprehensive health promotion programs, screening, one-on-one health counseling

• CMS now recognizes that management of chronic conditions is usually done in primary care offices and requires time and resources. • However, focusing on patients with 2 or more chronic conditions can improve their healthcare quality and reduce costs. • Beginning in January 2015, a new CPT code al ows chronic care services specifical y for Medicare patients with 2 or more chronic diseases. Carnegie Mellon (2007) Study: "Blue Shield of California's
Comprehensive, Community-Based,
Patient-Centered Management" reported:
"The 18-month study of case management program with members diagnosed with chronic il ness showed a 2:1 return on investment" • Reduced hospital days by 36 percent • Reduced hospital admissions by 38 percent • Reduced emergency room visits by 30 percent • Overall cost reduction of 26 percent • Chronic disease and condition, including diabetes, obesity, COPD, heart disease are among the most expensive, common and preventable health issues in the United States • 2/3 of Medicare dollars are spent on patients with 5 or more chronic conditions • Research consistently shows that effective chronic care management reduces cost of care for patients AND improves their overal health • Chronic disease patients are left to coordinate their own between-visit care resulting in frequent ED trips, frequent inpatient stays, fragmented health data, duplicate testing, increased cost, AND poor health outcomes. MAPs Role and Purpose • Applies to Medicare Advantage Plans (MAPs)
– 28% of all Medicare beneficiaries currently enrolled in MAPs (and this number is increasing)
U.S. government and private insurers joining
forces to expand MRA methodology
– Stated goal is to shift 76% of business to contracts with incentives for quality and lower‐cost – Idea is that changing reimbursement system will speed needed provider performance changes
Federal health standards call for 30% of
traditional Medicare payments to be tied to
alternative payment models by 2016 and 50% by
2015 HCPro, a division of BLR. MRA System and How it Works • Uses only ICD system diagnoses codes (plus
demographic info)
- Codes from claim form submission - Codes must be supported by physician
Each Medicare beneficiary is assigned a
cumulative risk score based on all diagnoses (ICD
codes) submitted within a given calendar year.
How Risk Adjustment is Calculated: • The numeric sum of patient demographics PLUS the patient
health status = MRA (Medicare Risk Adjustment)
• Al the diagnosis codes and demographic facts are assigned a specific numeric value that reflects the importance in determining the resources required for that beneficiary group
OUTPATIENT documentation is 80% of the patient's health
• AND the patient's health status comes from diagnosis codes submitted on claim forms from Outpatient and Inpatient More MRA Calculations: • Some ICD codes weigh more (RW) than others indicating
diseases that are more resource-intensive to treat.
So in comes:
Hierarchical Condition Categories (HCCs)
• The HCC include about 3,000 ICD‐10 codes that have been
assigned to 70 high‐risk condition categories
• Each category is given a risk factor value
• These categories measure disease complications by
associating certain diagnosis codes to more than 70 chronic
clinical categories
• These are used to demonstrate how sick patients are in a
given Primary Care Practice
• CMS then pays Medicare Advantage Plans (MAPS, Humana, BCBS, UHC, etc.) administrator an amount to average the risk score of all beneficiaries for which it is – That amount is expected to cover all costs necessary to take care of that population for the next calendar year
Therefore, MAPs want beneficiary risk levels as high
as possible!!!!
– MAPs are wil ing to share some with the providers who do the documentation
Primary Care Providers diagnosis code selection is the
most important and the critical piece of information on
that claim form!!!
Hierarchal Condition Categories Explained:
The 70 HCC's common chronic diseases that primary care
providers do not document on routinely:
• DM/w manifestations • Chronic respiratory failure More Specifics:
HCC scores can change from year to year based on the codes submitted • HCC capture is based on physician documentation at each clinic encounter. • Chronic conditions treated on an ongoing basis must be coded and submitted as many times as the patient receives treatment and care for those conditions. The Provider Problem:
Most PCPs fail to routinely document chronic illness on a clinic visit -- they are problem-focused on what brought the patient to the clinic. Providers wrongly think they can't submit a claim that lists
diagnoses not addressed at that particular visit.
HOWEVER, each HCC needs to be documented/submitted on a claim at
least once per calendar year.
Example: If the provider fails to document an amputation
during a calendar year, the payer will take the position that the
limb grew back!!!
Remember: Just documenting a condition in the medical record is
The condition MUST be submitted to the payer on a PAF or
claim form!!!
Chronic Care Management in the Clinic
• CCM is the non-face-to-face services provided to Medicare patients who have 2 or more chronic conditions. • These services provide communication with the patient and provider for health care coordination and medication management, with 24/7 accessibility. Here's what's needed: An individual, comprehensive electronic care plan for each patient in the health care record. A CCM services team for contacting patient (can be CMA, LPN, RN). "Contact-based care"- 20 minutes of non-face-to-face time according to the patient contract, with coordination of care. Certified EHR that has a summary of care record (care plan) that can be maintained and accessed at any time by staff and provider. BILLING:
CPT Code 99490
¶ Payment is $42.60 per month per patient is the average reimbursement, adjusted based on geography. ¶ Must have patient contract and consent. ¶ Only one primary care provider can be paid. ¶ Co-payments do apply. The following cannot be billed during the same month: √ Transition Care Management √ Home Healthcare √ Hospice Care √ Certain ESRD services √ CPT 99495 or 99496 Chronic Care Management Steps:
Step One Medicare Requirements:

Identify the Medicare population with 2 or more chronic illnesses that are at least 3 months old and will last for 12 Then obtain the Medicare patient's consent to participate: ► Must sign a consent form ► Design a care plan that fits their needs ► Program description and how it is provided ► Only one practitioner can provide services ► Health information will be shared with the team ► Associated co-pays and deductibles that apply Chronic Care Management Steps:
Step Two EHR Technology Requirements:

Must be certified -- 2011 or 2014 of the certification criteria
for the EHR incentive ► Must include the following patient data: problems, medications, allergies, demographics ► Allow for the creation of a structured clinical summary ► Must be able to transmit the summary record for purpose of care coordination ► Documentation from the home and community based ► House the Medicare patient's care plan ► House the consent to participate in CCM services Chronic Care Management Steps:
Step Three CCM Service Requirements:

Must have RN manager
Must have office space for staff
Staffing needs (CNA, med tech, hospital experience)
One staff for every 300 Medicare patients on the plan
Telephones with headsets
Computers on the clinic software
On-call system for 24/7 patient access
►Ability to make successive appointments with provider ► Provide 20+ minutes of non-face-to-face care Chronic Care Management Steps:
Step Four Electronic Care Plan

Ability to share the care plan with providers and team
Ability to update with each phone call
Care plan to cover physical, mental, psychosocial,
cognitive, functional, and environmental assessment of patient with each phone call Medication reconciliation on each phone call
Ability to provide the patient with a copy of the care plan
Includes problem list with measurable treatment goals
Indicates community and social services that are ordered
Chronic Care Management Steps:
Step Five The Enrollment Process

► Design a campaign that reaches out by phone and mail to each eligible patient, educating them about the value of Chronic Care Management. ► Allow each eligible patient to select their provider of choice. ► Make an appointment for the patient to visit the office to be seen by their provider. ► Go over the CCM agreement, go over the care plan for their chronic illness, and tell the patient they have a right to stop CCM services at will. ► Within a few weeks of enrolling, the patient receives the first phone call from the Chronic Care Coordinator they are What is CMS Looking For????
In general, a care team to provide patient-centered-solutions with 24/7 care coordination that provides:  Medication reconciliation  Effective monthly reviews to update the Care Plan and Problem List  Having a 1:1 conversation with the patient to address self- management and adherence to medication protocol  Monitoring the patient's physical, mental and social condition  Ensuring that all preventive services, DME equipment and community resources are utilized for each patient  Phone reminders for visits and therapy AND MORE:
• E&M or procedural services are billed as appropriate AND separate AND can be as often as the providers deem it necessary. • Documentation and the Care Plan is the key: • Document patient consent • Document 20 minutes of non-face-to-face clinical time • Document on care plan each phone call or any updates • Document any after hours conversation • Document any coordination of care in the care plan • Document any conversation with the provider Medicare Payment for CCM and RHC
• "As of January 1, 2016, RHC's can bill for CCM services, furnished by, or incident to, a physician, nurse practitioner, physician assistant, or nurse midwife for an RHC patient. • CMS proposed a separate payment for RHC's providing CCM services that is separate for the RHCs AIR. • The proposed payment for CCM services will be based on the Physician Fee Schedule Payment for CPT code 99490 • The code could be billed as a stand alone service OR with other payable services on the RHC claim. • The current payment rate for CPT code 99490 is $42.91 per beneficiary per month." CMS Documentation Guidelines
• Medical record documentation must be legible
• Physician's signature and their credentials must be
included on each patient encounter
• Documentation must be dated for risk adjustment
validation purposes
• CMS only considers medical record documentation
from a facetoface encounter
• Must be coded according to ICD‐9/ICD‐10 guidelines
• Code all documented conditions at the time of the
visit that affect a patient's care
What can a Primary Care Provider Do to Improve:
*** Capture each patient's Severity of Illness (SOI)
1. The higher the SOI, the more expected to spend - $$ increase
Capture more HCC, ensures higher patient SOI Extra cost will be expected as the patients are "sicker" 4. Your MER/MLR will improve PCP may not be motivated by money….Soooooo …….
Healthcare is going from a Quantity-based system to a Quality-
focused system

Payers are monitoring PCP performance and making the statistics public: Medical Expense Ratio (MER) vs Medical Loss Ratio (MLR) Actual $$$ spent in a year/actual $$$ expected to spend >100% --- PCP cost the plan money 85-99% --- Plan broke even < 85% --- PCP made money for the plan Payers are making network participation decisions based on these metrics CMS Documentation Guidelines
• Chronic conditions treated on an ongoing basis may
be reported as many times as the patient receives
• Address chronic conditions at least every 6 months
• Document specificity of condition
• Link diagnoses with manifestation
• Use Z codes when appropriate
• If it's not in the note, it didn't happen!
CMS Documentation Guidelines
• Results of lab and radiology reports must include interpretation of those results in the note – May not simply be copied into the note – CMS does not accept signatures/initials with a date on the actual lab or xray report as adequate documentation – CMS does not accept a copy of the note in the medical record that states results were mailed to the patient • Condition of findings must be discussed and noted in the face‐to‐face encounter Documentation Responsibilities:
Documentation must support that the condition was
addressed AND discussed:
√ Status of condition √ Physical exam Ordering labs and medications without linkage to treatment plan does not validate the diagnosis. Sample Assessment & Plan
Medications added to medication list this visit:
1. Lunesta 2 mg tabs … one po at hs
2. Macrodantin 50 mg caps … one PO daily
3. Pravastatin 20mg … one PO at HS
Problem #1: Long‐term (current) use of other medications (ICD‐V58.69) –
Zolpidem, wants to try Lunesta
Problem #2: Insomnia, chronic (ICD‐307.42) – wants to try
Lunesta for lower costs
Problem #3: Varicose veins, lower extremities, mild (ICD‐454.9) – due to source
of pain will obtain US.
Future orders: US Venous Doppler Unilateral (CPT‐78457)
Why is the patient on Macrodantin????
Why is the patient on Pravastatin???
What are the chronic problems?????

2015 HCPro, a division of BLR.
More Documentation:
• Patient's present drugs and their management need to be - Even if you make the decision to keep the patient on
the same dose.
This allows you to document a diagnosis for the drug, and it will be submitted on the claim form. • Document all chronic conditions and their treatment – "Patient continues with diabetic diet" or "Continue home blood sugar monitoring" -- CMS considers this notation sufficient to meet their criteria --
And More Specifics:
• RAF (risk adjusted factor) is assigned to each HCC diagnosis • The total of each diagnosis RAF tells a patients overall health – An average RAF score of 1.0 is a typical patient – Total scores >1 are "sicker" and will consume more treatment – Total scores <1 are healthy patients The specific diagnosis risk scores are set by CMS with Thomson Reuters MarketScan * data used for calibration Problem List:
– Not sufficient to document what is going on with the patient – Not accepted by CMS for Medicare Risk Adjustment – Problem list does not make it on a claim form – Problems/diagnoses must be addressed in assessment & plan – Problem list need ICD codes, coders cannot code from problem list without issue being addressed – Diagnoses need to be re-evaluated in the medical record at each office appointment Problem List:
• To validate each chronic illness, each diagnosis must show evidence of eval & treat on the date of service: - Status of condition - Referral to specialist - Medication refilled - Education - Test ordered and reviewed !!! NO!!!
Medicare Beneficiary Requirements Technology Requirements CCM service Requirements Phone Center requirements Staffing Requirements How do you accomplish al this????? Option #1
• Do It Yourself- –Construct the team –Hire the staff –Build electronic care plans –Buy/install care management software –Location for call center Option #2
• Partner with an Outside Vender: –You supply the patient base and consent form –They supply a turnkey solution –Staffing, phone calls, software –Electronic care plans provided –Software integration for billing CPT code –24/7 call services –Medication monitoring, community services and appointments made –Usually all done off site, usually in another state, usually in a large city • They are charging 60% and up…… Option #3
• Hospital as vendor, partner with clinics: –Builds relationship between hospital and –Hospital supplies call center, phones computers and staff –Clinic supplies patients and consents –Calls made locally –Hospital or clinic does billing –Hospital captures 40% Always An Option:
Consultant for Chronic Care Management: • Assist with assembling the CCM team • Identify Medicare patients with 2 or more chronic illnesses • Design patient consent • Train Care coordinators • Train Providers • Assist with call center logistics, phones and computers • Design care plans • Train CCM manager • Audit calls and care plans • Assist billing with chronic care claim form • Follow up post implementation Potential:
• 5500 Medicare patients registered in the clinic • 3000 with 2 or more chronic diseases • 3000 phone calls per month = 10 employees • 3000 x 42.00 = $126,000 • 60/40 split with vendor Value-Based Purchasing Modifier
• Will account for differences in patient SOIs that affect medical costs, regardless of the care provided • Is risk adjusted so practices can be compared more fairly • Those with large numbers of high‐risk beneficiaries will have their costs of care adjusted downwards • Those with large numbers of low‐risk beneficiaries will have their costs of care adjusted upwards • Note: Costs are risk adjusted prospectively using prior year
CMSHCC (Hierarchical Conditon Categories) risk scores
2015 HCPro, a division of BLR. Solutions to Ponder:
• Hire additional medical assistants &/or scribes to help with documentation needs (paper or EMR) – No rule exists that EMR documenter must be the PCP – Easy to justify as can also increase office‐visit volume • Emphasize HCC capture at staff meetings, with each patient visit • Hire a CCM clinic specialist • HCC cards with top diagnosis for clinic • Have consultant audit charts every 4 months Key Takeaways
• Options for care management are expanding and may encompass CPT codes 99495 and 99496 for transition of care in the near future • Remote monitoring can soon count for the time per month for • Patients may receive CCM services from just one practice • Timely and effective enrollment activity is essential to build a sufficient panel to support viability • Each phone call is 20 minutes, billable CPT 99490, by a care coordinator who can be a LPN, med tech or CNA • Only one provider/physician/clinic can bill for 99490 • Must furnish 24/7 on-call phone number for CCM participants


Hypertrophic cardiomyopathy: management, riskstratification, and prevention of sudden death William J McKenna and Elijah R Behr 2002;87;169-176 Updated information and services can be found at: These include: "Web only references" This article cites 23 articles, 16 of which can be accessed free at: 17 online articles that cite this article can be accessed at:

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