Chronic care management codes worthwhile if done right

The uptake of billing the chronic care management (CCM) codes, which were introduced in 2015, has been mixed.

Initially, most practices met the codes with skepticism because they seemed to be more trouble than they were worth. Many physicians, especially those in smaller practices, found that implementing CCM in their practice required hiring a dedicated person to manage the patients, which made it a risky venture.

However, most of those who have been using the codes have found that the reimbursement at least covers the cost of the additional care coordinator, that the codes have been profitable, and/or that they have improved outcomes for the participating patients. While much of this information is anecdotal, there is increasing evidence supporting the use of these codes if done smartly.

One of the biggest barriers to billing the CCM codes initially was the requirement that patients must agree to participate in person, which required getting those with two or more chronic diseases into the office for a visit specifically to do that. However, new rules make it a little easier by allowing oral consent to participate in the program. Now a practice can call the patient, explain how the program works, and document the conversation in the chart.

It is important that clinical staff or clinicians keep a record of time spent with participating patients and that the care coordination is appropriately documented and clinically necessary. In addition to keeping track of the time, such as using a log of some kind, they also need to make sure it is documented in the chart (in case of audit). In other words, time spent coordinating care or talking with the patient must be for a reason, such as following up after a dose change or lab result, scheduling testing, or returning a patient call, and not just for the sake of checking in.

The clinical staff providing the care coordination can be an existing staff person or, depending on the size of the practice and the number of patients who qualify, a new part-time or full-time hire. Clinical staff is defined by Current Procedural Terminology (CPT) as “a person who works under the supervision of a physician or other qualified health professional, and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.” Many commercial entities now offer CCM services on a contract basis to practices, but physicians should exercise caution before entering into such relationships. Practice staff know the patients and clinicians, as well as local subspecialists, facilities, and testing entities, best.

The Table shows the summary description and national average payment for each of the CCM codes.

It is important to note that the complex CCM codes are intended to be for those patients who really are complex. Most likely, it is expected that most primary care physicians will not use these codes frequently, except perhaps in geriatrics or oncology or during those occasional months when something significant is going on with a patient that requires additional care from the team.

Time spent on care management in the ED counts, but time spent while a patient is an inpatient or in observation care does not. Time spent personally by the physician may also be counted toward the clinical staff time (but not time spent during another billable service, such as an office visit).

CMS offers a helpful fact sheet about implementing CCM codes in practice. For more detailed billing tips and step-by-step implementation guidance, see ACP's CCM Toolkit. For more detailed descriptions of the criteria and requirements, see the Care Management section of any CPT book your office may be using.