FAQ about CCM

Chronic Care Management
Frequently Asked Questions

Getting Started

What exactly IS the CCM requirement?
"Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care 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)

Why should I outsource this service?  Can't I do it myself?
You could do it yourself, but do you want to?  

  • There's a minimum of 20 minutes per month, and you're required to provide the full scope of services each and every month.  We know that it takes quite a bit more time every month.
  • We have to stay in contact with the patients, their families, and every one of their other providers.  
  • We have to make our clinical staff available 24/7/365.  
  • We have to get medical records from all the providers, and continue to do so every time there is a visit.
  • We have to translate the medical records (about 1/3 still come in via fax) into discrete fields and create Care Reports.
  • We've already created a secure collaboration platform and Care Reports that go beyond the CMS requirements.

What patients/what chronic conditions are eligible?
CMS has stated they have left the ruling open to discernment by the provider.  The guideline simply requires:

  • 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

What providers are eligible?
CMS' intent was to have primary care coordinate, but the code allows for any provider to perform the CCM service. Of course, if you're a specialized surgeon, you may not be as interested in routine chronic care, and we would have to coordinate schedules closely, as CCM minutes do not count during the post-op period for the CCM billing provider.



May I see a copy of the consent form?  
Of course!  CMS did not provide a standardized form, so we created one based on their requirements and our unique service.  Click here to view the sample

How does the form get signed?
It's easy with our SignQ technology.  Simply create an invite from the software Admin area, and we'll email instructions with a digital form to the patient, and we will also provide a form to have signed in the office when the service is prescribed.  We provide materials as well, so the patient is fully informed and ready to use it.

When can the patient be enrolled?
CMS requires the billing practitioner to furnish an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (IPPE), or comprehensive evaluation and management visit to the patient prior to billing the CCM service, and to initiate the CCM service as part of this exam/visit.  CCM can be billed for this first month if the consent form is signed and the required elements are performed.

What if a patient is eligible, but doesn't have access to technology?
One of the best things about our software platform is that it's designed to engage the entire family and care team. We have found that most of our users love their iPads and other devices, and even if they only intended to use them to view grandbaby pictures, they quickly master them. If a patient is eligible and doesn't have access to email or a device, though, we invite the appropriate caregiver and close the loop with that person.  Our Care Coordinators coordinate care with the entire team on behalf of the patient, so the reports and data are absolutely accurate and effective, even if the patient doesn't personally engage.

What if I enroll a patient, and he isn't qualified?
Let us know before the end of the period, and we'll remove the plan without charge. We'd like to keep you connected with your patients, even if they aren't enrolled in CCM, so you can continue connecting with them on our software platform and receiving the Care Reports with patient-generated data.

What if a patient wants to discontinue the service or switch to another CCM provider?
Only one provider may bill on any given month. The patient must notify the provider in writing, and the service will cease on the last day of that month.


Our CCM Services

How do we achieve each of the Medicare requirements for 99490?
Here are the specific requirements, with our coverage of each:

  1. 24/7 Access to Clinical Staff.  Our Care Coordinators are available 24 hours per day, 7 days per week, via phone, email, and in-app messaging.
  2. Continuity of Care.  Our Care Coordinators help patients schedule appointments with the designated provider and ensure comprehensive health information is consistently shared with the entire care team.
  3. Care Management.  When the provider creates an Assessment and Plan, Care Coordinators will obtain the information to create tasks, medication & measurement reminders, and more important information in a format that the patient and care team can easily understand and engage.  The information is completed and updated to the provider, who is able to adjust the care plan according to documented results. A complete, current list of all conditions, medications, allergies, and more are always available to every provider via a free CareSync account, and pushed monthly via Blue Button and other methods to ensure the information is easily available at the point of care and that all providers have reconciled data.
  4. Care Plan. A comprehensive Care Plan is created with the required elements: Problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community/social services ordered, coordination of other agency and specialist services, etc.  To accomplish this, CareSync's Health Specialists retrieve this information from the patient, the patient's care team, and the Assessment & Plan gathered from each of the patient's active providers.  The comprehensive health information is always available to every member of the patient's care team, as each provider and family member is offered a free CareSync account.
  5. Care Transitions.  Our Care Coordinators refer patients to other clinicians in a timely manner, retrieve the records from each visit associated with the trigger event, update the patient's information, and share it with every member of the care team.
  6. Coordination with Other Providers. Every visit with the primary care team as well as home- and community-based providers is recorded, the Care Plan is updated, and every Provider has access to the documentation via the free CareSync application and pushed updates. If the Plan includes a referral to another provider or service, all the providers can view the activity associated with it.
  7. Patient and Caregiver Access (Asynchronous).  CareSync was created with the idea that caregivers are often the best source of information about the patient.  The revolutionary ability for families to interact with the information, share information before the visits, listen to a recording of the doctor's instructions, and respond to notifications when a reminder is missed ensures that CareSync caregivers have the best possible opportunity to facilitate patient care and give the provider a new level of useful data.  Caregivers get email and device notifications and activity summaries, and are encouraged to interact with the patient and Health Assistants via in-app comments and notes.

Does CareSync do anything beyond Medicare's requirements?
We're glad you asked!  These are just a few:

  • Timeline.  CareSync's trademarked Health Timeline is an important part of the patient's history and the care team's understanding of what has been done lately.  The most recent 30 days of Timeline activity is included with the monthly update to all current providers. 
  • Caregiver Accounts.  The patient's family members and other caregivers not only have access to the patient's information, they are encouraged to create their own accounts so they are truly engaged with the application.  
  • Medication & Measurement Reminders. Medication & measurement instructions are part of every Care Plan, but CareSync turns it into an engaging opportunity to generate useful data and complete the communication loop with the providers.
  • Visit Planning Tools.  Many patients forget what they were going the ask the doctor at a visit, and even more forget what they were told.  Patients and caregivers are encouraged to plan the visit by adding notes and tasks that are transmitted to the provider before the visit. A voice recorder built into the app allows the doctor's explanations and instructions to be saved to the visit and are immediately available to the entire care team.
  • Medical Records.  In order to review the patient's Assessments and Plans, the Health Assistants get actual medical records from each of the current providers, and records for any visit while the patient is a CCM plan member.  The records include SOAP notes, images, lab results, and anything associated with the visit.

What sort of credentials do your Health Assistants have?
A licensed physician and an experienced registered nurse oversee the daily activities of our Services department.  The Health Assistants include nurses, medical assistants, CNAs, and others.

Is your technology HIPAA-compliant?
Of course! Everyone on the CareSync team has signed the required HIPAA agreements as well.

Is CareSync a certified EMR?
No. CareSync is not an EMR, it is a collaborative, family-centered Personal Health Record. We use the same databases that certified EMRs use to create useful information from all the records we get--even the data from paper records is hand-keyed into discrete data fields.  CMS requires that a certified EMR is used by the billing provider, so we will get a copy of your EMR's certification, and all the data will be available for you to receive into your EMR.

How do you comply with the CMS electronic communication requirements?
We go beyond the minimum requirements to make sure every provider has access to all the information in a way that works best for the practice. Information is shared on the secure CareSync platform, Blue Button transmission of data via download or secure email so that providers can receive it into their certified EMR systems, and we fax a backup copy to providers in case they haven't logged in.  Click for more information on CareSync's Blue Button feature.  


CCM Code Restrictions

Can I bill for patients I see via video or phone conference?
Exciting new guidelines are being established for telehealth medicine.  Here is an interesting article that talks about the possibilities.

What types of patients & care delivery systems are excluded?
Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC) may not participate, unless they have approval to bill non-RHC or non-FQHC services.  From what we have been hearing, that is expected to change for 2016!

What restrictions are there on my insurance contract?
Fee-For-Service (FFS) contracts are eligible.  At this time, capitated contracts do not cover 99490 (although the CMS ruling stated they will evaluate it).

Is there a time when a patient covered by CCM is not eligible for the service?
Yes.  There are four types of services that cannot overlap with CCM services on the same day, as the care management component is built into the other service.  You must advise CareSync so we do not count these minutes toward the CCM requirements.
- Transitional Care Management (99495, 99496) 
- Home Healthcare Supervision (G0181)
- Hospice Care Supervision (G0182)
- Certain ESRD codes (90951-90970)

What if I have a patient in one of the above situations, such as a Transitional Care Management period?
You can't bill CCM and TCM in the same calendar month, but CareSync's services will continue, and will cover many, if not all, of the TCM requirements. You will receive the benefit of the service and you'll bill a typically higher-paying code.


Billing Details

What insurance plans will pay this code?
Medicare and Medicare Advantage plans. We understand that commercial plans are evaluating now and plan to accept it soon.

What is the expected payment?
The average reimbursement is about $43.  The payment amount is subject to geographical adjustments, but you can get a good idea of what your reimbursement in your area will be with the CareSync Revenue Calculator. Click here, choose your region, and enter in the numbers for your practice.

How do I know that the diagnosis codes in CareSync are the same ones I'm using to bill?
- You and your staff have unlimited access to the CareSync account.
- We will provide a Current Health Summary with the active Health Conditions each month.
- We will provide a monthly billing report with all the patients who had 20 minutes or more of CCM services, and the report includes the active Health Conditions. We can update the patient's Health Summary if there are any discrepancies.

How are the care coordination minutes tracked?
CareSync's care coordination technology tracks the minutes for each patient-related activity we perform, and the totals are included in your monthly billing report.

What if you don't achieve the required 20 minutes?
While we are certain there is enough coordination work to go way beyond the minimum time, we will notify your staff if we don't have enough to do for a patient.  If your team has tasks associated with this patient and can make up the difference, you'll have the report of our minutes. If we don't make the 20 minutes, we won't charge you for the month.

Is my patient responsible for any payment?
The same as any other billable code, the patient is responsible for deductibles, copayments, and remainder amounts according to the patient's insurance agreement.  99490 is not exempt from cost-sharing rules, unfortunately, so Medicare Part B patients with no secondary coverage will be responsible for about $8/month. The intent of the code is to reduce costs for all parties, including the patient. Better coordination means fewer visits, which in turn reduces the patient's overall out-of-pocket expenses.

What are the billing details?
According to the AAFP interpretation, the following should be used for billing:
- Date From/Date To:  First and last days of the month.  Do not bill before the month has ended.
- Location:  Use your usual location for where you see patients for evaluation & management.
All other details should match your normal coding procedures. Make sure you have recorded the exact times for the 20 minutes of service that were performed in case of an audit!


More On The CMS Ruling

Can I view the original ruling document?  
Of course!  It's on the CMS site, and here is the link to it.

What's next with CMS and chronic care?
We don't know, but we're watching it very closely and we'll keep you posted!

Have more questions?
We're navigating this together, so let us know and we'll find out for you! Also, you can download our CCM infographic here.