CCM and MACRA for Primary Care

Chronic Care Management and MACRA Strategies for Primary Care Providers

CCM and MACRA for Primary CareEven though the recent CMS announcement regarding potential MACRA changes may extend its timeline and increase flexibility for health care providers, many primary care practices are still focusing on dedicating resources to determine strengths and opportunities for improvement, in order to succeed in a value-based payment program. MACRA is a long-term commitment towards value-based care and payment models that require detailed analyses and strategic cross-functional planning, which take time, so it is important that providers start looking into the strategy that will work best for them.

Chronic Care Management and MACRA

In 2015, Medicare began paying separately for chronic care management services (CCM) for care coordination services for patients with 2 or more chronic conditions expected to last, at least, 12 months. CCM was a way for CMS to begin rewarding providers for engaging patients in their care and improving outcomes, which would decrease costs in return. Later, in October 2016, CMS issued the final MACRA rule — a way for CMS to incentivize providers to attain the Triple Aim in health care – better patient care, improving the health of population and reducing costs. This is why practices that already have a CCM program in place may be ahead in the transition to MACRA’s Quality Payment Program.

About Chronic Care Management Services

Chronic Care Management services include:

    • Phone calls and emails to discuss management of chronic conditions
    • Management of prescriptions
    • Management of referrals
    • Review of patient status

 

The following health care providers can bill for CCM services:

 

The following are the CPT codes that providers can bill for CCM services:

  • CPT Code 99490 – This code can be used when Medicare is billed for, at least, 20 minutes of clinical staff time directed by a qualified health care professional to coordinate care for beneficiaries with chronic diseases. The national average as of January 2017, is $43 per patient per month.
  • CPT Code 99489 – This code is to be used as an add-on to complex CCM CPT code 99487 for every additional 30 minutes of clinical staff time for moderate or high complexity cases.
  • CPT Code 99487 – This code is for complex CCM that requires 60 minutes of staff time to establish or  for substantial revision of a care plan of moderate to high complexity.
  • CPT Code G0506 – This code is as add-on to the initiating CCM visit describing the effort of billing and care planning for cases of higher complexity.

In order to be able to submit a claim using CPT 99490, providers must show the following:

  • 24/7 access to clinical staff
  • Continuity of care
  • Care management
  • Comprehensive care plan
  • Care transitions
  • Home and Community-based care coordination
  • Enhanced communication opportunities not only through phone, but also through text message, internet and face-to-face meetings

For more details about billing codes, read our CCM Final Rule summary.

Succeeding in MACRA: CCM Strategies

Health care providers have two tracks to choose from, under MACRA’s QPP: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Below are some examples on how having a CCM program in place could make the transition to a MIPS easier.

Several measures under the Improvement Activities in MIPS, such as care coordination, align with CCM requirements. This means that your current workflows may not need any further adjustment, in order to meet the requirements under this measure. Building an IT infrastructure with interoperability necessary for care coordination takes time, so PCPs who already have implemented a CCM program will be one step ahead than those who don’t have one in place.

For example, under the Improvement Activities category in MIPS, providers can report under “Chronic Care and Preventative Care Management for Empanelled Patients” as one of their minimum of 4 improvement activities. Similar to CCM, this activity calls for “Use of condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target; Use of pre-visit planning to optimize preventive care and team management of patients with chronic conditions; Use of panel support tools (registry functionality) to identify services due; Use of reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due; and/or Routine medication reconciliation.”

CCM also aligns with some Quality Measures in MIPS. Under MACRA, physicians must create a comprehensive care plan and have to demonstrate patient engagement, and care coordination. For instance, one Quality Measure is “Hypertension: Improvement in Blood Pressure,” which would already be included under CCM services.

Similarly, under the Advancing Care Information category, the “Security risk analysis” measure requires providers to conduct or review a security analysis of patient data created or maintained by certified EHR technology. Because, in order to get paid under CMS Chronic Care Management program, providers are required to have a certified EHR system, CCM providers could report on this measure as a way to meet, at least, the minimum requirements to avoid a penalty.

As you can see, there are several ways that CCM and MACRA overlap. PCPs who recognize these similarities will have a higher chance of succeed in value-based care models.

With over 270 reporting measures under MACRA, narrowing down options to CCM activities/measures your practice is already submitting for payment and are already show improvements in care quality, outcomes and cost, will make the transition to value-based payment easier. Because MACRA requires providers to not only report, but also show positive performance, showing chronic care coordination efforts and their outcomes may help maximize potential incentives (or help minimize penalties).

Does your practice have a CCM program in place? How has this helped you with the transition to MACRA? Please share your thoughts below in the comments section.

If you’re interested in learning more about increasing your revenue through CCM services, or looking to build a strategy to move to MACRA, contact us to schedule a consultation by filling out the form below.

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