Advancing The Profession of Pharmacy

Chronic Care Management and the Consultant Pharmacist

by | Aug 16, 2018 | Consulting Pharmacist Education

 

Would you like to watch a video version of this post?  I’ve got you covered!

Chronic Care Management Services

​Medicare is rewarding new processes aimed at improving patient care and reducing healthcare expenses.  One new program that became eligible for physician reimbursement is a program intended to monitor certain patients with multiple chronic conditions.As of January 1, 2015, Medicare is paying for a non-face-to-face care coordination service through use of billing code 99490.  The Chronic Care Management Services may be provided by phone or tele-health by a qualified health care professional under the physician’s general supervision.  ​

The service is usually offered as a 20 minute contact once every calendar month.

An estimation provided by this CCM calculator shows that just 50 enrolled patients could equate to an additional $25,560 in revenue for the practice each year. ​

This is a relatively new program that an entrepreneurial pharmacist could easily implement for multiple physician groups in their area for a fee.

Eligibility

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 requires the billing practitioner to furnish one of the following.

Prior to billing the CCM service, and to initiate the CCM service as part Patient Agreement of this visit/exam.

  • A comprehensive evaluation and management (E/M) visit
  • Annual Wellness Visit
  • Initial Preventive Physical Examination (IPPE)

 

Care plan elements

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of the individuals responsible for each intervention
  • Medication management
  • Community/social services ordered
  • A description of how services of agencies and specialists outside the practice will be directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan

12 Components of CCM

  1. Problem list, PMH, medication list, allergies, etc.
  2. ​Access to care management services 24/7
  3. Continuity of care with established provider
  4. Care management for chronic conditions
  5. Creation of patient-centered care plan to share with all stakeholders
  6. Provide beneficiary with written or electronic copy of care plan and document in EMR
  7. Management of care transitions between providers and settings.  Plan for follow-up after any care transitions.
  8. Coordination with home and community-based service providers.
  9. Enhanced access to care provider (secure messaging, etc.)
  10. Document offering of services to beneficiary.
  11. Document beneficiary acceptance/right to revoke.
  12. Document informing patient only one provider can bill for these services per month.

CPT Codes

The two key differentiators between 99487 and 99490 are the additional time (60 minutes for CPT 99487 from 20 minutes for CPT 99490) and the requirement around medical decision making. In addition, a code reimbursing for additional time (CPT 99489) is available for complex CCM patients being billed under CPT 99487.

Provider can bill for G0506 in addition to the AWV/IPPE billing

Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services (billed separately from monthly care management services and MAY BE ADDED TO AN AWV- but must be seen by a QHCP)

The G0506 code is particularly appropriate when the CCM initiating visit is a less complex visit (such as a level 2 or 3 E/M visit). G0506 can be billed along with higher level E&M visits if the practitioner’s effort and time exceeded the usual effort described in the initial visit E&M code. G0506 can also be billed when the initiating E&M visit addresses problems unrelated to Chronic Care Management and the CCM related work is not included in the initial visit code.

Could be face-to-face and/or non-face-to-face, but the time spent doing the CCM care planning must not already be reflected in the CCM initiating visit itself or in the time spent during the monthly CCM (i.e., in CPT 99490, CPT 99487, CPT 99489)

G0506 is meant to be billed only once per beneficiary during the initiation of the patient into Chronic Care Management.

What do are your thoughts?  Would this be a viable business model in your area?  Leave a comment below.

Leave me a note in the comments or join our Pharmapreneur Community Newsletter and email me directly!

About the Author

Blair Thielemier, PharmD, is an MTM consultant pharmacist specializing in pharmacy billing models. She consults on and produces e-learning programs for state and national organizations, pharmacy wholesalers, payers, technology start-ups. She has books and online courses available for individuals looking to leverage their pharmacy knowledge into monetized clinical programs at PharmapreneurAcademy.com. She speaks internationally about trends in leveraging pharmacists to improve value-based care.

 

Let Us Help You Become
THE Pharmacist To Call

Join today!

 

Consulting Pharmacists Education Archive