Showing posts with label Chronic Care Management. Show all posts
Showing posts with label Chronic Care Management. Show all posts

Monday, October 23, 2023

4 Reasons your medical practice should combine remote patient monitoring and chronic care management

For practices looking to scale their care coordination strategy, there is a long list of reasons why a combined chronic care management (CCM) and remote patient monitoring (RPM) program is a winning formula. Currently working for hundreds of practices around the country, the combined approach is leading to higher provider and patient satisfaction, better care for patients most in need, and increased revenue opportunities.

Let’s define the equation. CCM is a model of care designed to support patients with diabetes, arthritis, heart disease, and other long-term conditions. Treatment is highly collaborative and includes routine, non-face-to-face monitoring of the patient's health, medication levels, care coordination, and more.

RPM leverages technology, such as digital devices and sensors, to remotely collect and monitor a patient’s health status. Overseeing everything from vital signs to glucose levels, RPM allows patients to stay connected to their providers, and engaged in their care, from their homes. Often, RPM programs include trained medical teams that are available through a mobile app or a video chat in case the patient has questions.

  1. Here are four of the top benefits practices can experience from a combined approach:Happier, healthier patients. The combined RPM and CCM approach—broadly referred to as remote care management—provides significant advantages to patients. Most patients qualify for both initiatives and, once they are onboarded, become highly engaged in both the programs and their individual remote care plans. Patients don’t know which program they’re enrolled in, nor would they likely know if they are enrolled in both. However, they do understand and care about the strong relationship between themselves, their doctor, and the care coordinators that they interact with. When technology can support that symbiotic relationship, the practice provides exceptional whole-person care.
  2. Better reimbursement potential. Dual enrollment of patients into a CCM and RPM program also improves the practice’s bottom line, maximizing reimbursement for remote care services, without placing an additional burden on physicians and staff. In fact, many practitioners find that they are already doing much of the work associated with both programs, but since they aren’t offering a formal program, they are missing out on the full reimbursement potential. Essentially, a dual program enables the practice to more appropriately categorize RPM and CCM services, and therefore, compliantly capture the services delivered that are best suited for each patient’s needs.
  3. Easily scalable remote care management. From a practice perspective, Chronic Care Management and Remote Patient Monitoring go hand-in-hand. The program enables practices to scale their programs quickly and easily—engaging and retaining most of their eligible patients. It’s also very easy to introduce, enroll, and onboard patients in both programs simultaneously. For example, if a practice is providing chronic care management to its patients with heart failure, it could easily incorporate remote patient monitoring of hypertension for many of these patients as well. Since heart failure patients typically have hypertension as well, enrolling them in both programs would allow the practice to treat the patient more holistically.
  4. More accurate vitals measurements to inform clinical decision-making. While CCM programs entail only patient self-reported vitals, RPM measures vitals through electronic devices. Both forms of vitals reporting are important, because they provide more context into the patient’s perception of their own health (CCM), as well as what’s really occurring with their condition (RPM). This creates additional opportunities to identify gaps in patient care, adherence, or understanding, and as a result, enables practices to more fully engage patients and build stronger patient relationships.



Other top benefits of a combined RPM and CCM approach include:

  • Improved patient adherence to care plans
  • More patient engagement and accountability
  • Early detection of health issues
  • More personalized care
  • Improved efficiency for providers

As practices face the aging patient population, ongoing staff shortages, and ongoing revenue strains, many are recognizing that a new approach to care is needed in order to continue thriving and providing optimal care to patients. A combined RPM and CCM approach can help.

While in-person office visits will always remain integral for maintaining physician-patient relationships and conducting in-depth annual evaluations, they can no longer remain a status quo. Rather, technology that facilitates ongoing RPM and CCM will empower a new paradigm of care.

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Tuesday, May 3, 2022

Hallmark indicators: Signposts to chronic care management

For clinicians, the key to chronic care management is having ready access to hallmark indicators that can mark the progression or control of a disease.These hallmark indicators (also called ‘key indicators’) are typically a set of six or seven measures that a physician would monitor, over time, to track the progression or regression of a particular illness. With diabetes, for example, indicators would include blood sugars, glucose levels, renal function, foot neuropathy, and other measures.

With easy access to hallmark indicators at the point of care, providers can proactively engage the patient, their family, and home care providers and make them aware that these are things that must be monitored closely, as they could indicate a problem.

Monitoring and reporting key indicators in real time can help communication between the provider, the patient, and the payer and make chronic care management vastly more efficient. However, the success of such a dialogue hinges on providing comprehensive, problem-oriented views of clinically contextual information to providers at the point of care.

Ideally, hallmark indicators are presented on a ‘dashboard’ at the point of care––providing physicians and nurses with at-a-glance access to historical data for the patient and the ability to identify trends and determine where a condition is heading. But most clinicians don’t have ready access to such information. Many indicators are results from lab tests, are not compiled in a list for a specific condition and are usually strewn throughout an EHR––packed in with everything else and requiring time and effort to locate.

One example of such a dashboard is at Phoenix Children’s Hospital, which has over 60 disease-specific panels displaying key indicators for clinicians to use at the point of care. Using them, the hospital reduced disease progression for juvenile arthritis by about 80% by actively monitoring a hallmark indicator––joint counts––both in the physician’s office or with the patient calling them in from home, and then coupling that information with the medications and lab tests. With that view, physicians can determine that by fine tuning the medications how they can improve outcomes. They are successfully moving the quality-of-life needle––both for the afflicted children and those who monitor their condition. Today, the hospital uses these dashboards to monitor 60 distinct diseases ranging from chronic lung conditions to gastrointestinal disorders and are seeing similar results.

This clearly illustrates that when clinicians are given the data they need in an accessible, consumable format, they can improve the quality of the patient’s life much more easily. The same is possible for nearly all the chronic diseases because they all have hallmark indicators. It’s just a matter of getting the right information in the right place, at the right time, in front of the right person.



The sharing of this information benefits payers as well. Payers are interested in reducing cost, which is done by keeping members out of the hospital and carefully managing their chronic conditions. The technology to make this connection exists. For example, there are many home monitoring systems to provide data directly from the patient to the HER, and then to the doctor. This allows the care team to see in real time if they are treating a particularly vulnerable patient who must have their insulin frequently adjusted. It’s an easy way to connect the dots.

The same applies for a condition like COPD. Symptoms such as shortness of breath can be reported on a phone and recorded into the EHR. The physician is alerted and can start intervention earlier. Similarly, with congestive heart failure (CHF) a sudden weight increase can indicate water retention, which could signal an exacerbation. Patients can track their weight with scales that log the results directly to a smartphone app, where it can be tracked in real time. If a provider and a patient are communicating––even electronically––there can be alerts set up. The provider can respond and ask about a weight increase, which could be as resolved with something as simple medication adjustment. Again, access to indicators and having an automated dialogue in place is essential.

Such real-time tracking is increasingly mainstream and will become more sophisticated over time. Apple now offers a watch that includes atrial fibrillation detection, and will soon offer blood sugar detection. These advances will make chronic care much easier by providing real-time data in a window where interventions can be applied patients become critically ill.

During my years as an internist, many of my patients had four or five different conditions, and many had some overlapping/common indicators. Multiply this by the number of patients covered by a practice, and you get a sense of how much data is flooding the medical record.

This raises the question: How does a clinician, in a timely manner, navigate and sort all that information to find the data pertinent to a specific condition? The data must be filtered and presented so the clinician has all the information pertaining to this patient related to this disease. To be effective, the presented information needs to be purged of ‘clinical noise’ to allow the clinician to focus on a particular problem. Then they can easily switch to the next problem and focus on that to make the needed decisions.

Clinicians are constantly putting this type of information into clinical context––in their heads. However, the volume of incoming data today is so immense that things can easily be missed. Since we have the technology, why not let the computers do the heavy lifting so physicians can drive better outcomes?


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Sunday, November 12, 2017

Are You Getting Paid for Chronic Care Management? Follow These Tips


Do you frequently review labs for patients with uncontrolled diabetes and educate them about self-management? Do you provide medication management support for family members whose loved one has Alzheimer’s disease? Do you provide ongoing support and education for patients with frequent acute exacerbations of chronic obstructive pulmonary disease?


If you answered ‘yes’ to any of these questions, you’re probably performing chronic care management (CCM)—a service for which the Centers for Medicare & Medicaid Services (CMS) began paying in 2015. But are you billing for it?

2017 Reimbursement for Chronic Care Management Services



When documented and coded appropriately, here’s what physicians can expect when reporting chronic care management (CCM). These are the 2017 national average Medicare payment amounts based on the physician fee schedule:



  • CPT code 99490 (CCM services, 20 minutes) = $42.71
  • CPT code 99487 (Complex CCM services, 60 minutes) = $93.67
  • CPT code 99489 (Each additional 30 minutes) = $47.01
  • HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring CCM services) = $63.88


Know When to Report Chronic Care Management


Though there is a laundry list of operational and documentation-related requirements that physicians must fulfill before billing CCM, Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO, owner of KGG Coding and Reimbursement Consulting, LLC, in Birmingham, AL, says the biggest challenge is simply trying to determine what patients qualify. Not every patient with a chronic condition needs CCM, she adds.

Per CPT guidelines, patients who receive CCM services must have two or more chronic continuous or episodic health conditions (e.g., heart failure, cancer, chronic kidney disease, or stroke) that a physician anticipates will last at least 12 months or until the patient’s death. These conditions must place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

The guidelines don’t provide a list of chronic conditions that would qualify, although Huey says CMS’ Chronic Condition Data Warehouse (CCW) is a helpful resource. The CCW includes 27 chronic conditions that CMS tracks in terms of volume and cost, and physicians can use it as a starting point when thinking about CCM.

“Some physicians would argue that, ‘By virtue of them having one of these conditions, they’re at risk of decline.’ But I really think it’s more of a judgment call that needs to be made,” she adds. “It’s not every patient. Some patients are managed well and have no issues.”

There are also a lot of conditions that are not in the CCW that could potentially qualify for CCM because they put patients at significant risk. Huey cites the examples of Parkinson’s disease, autism and Crohn’s disease.

3 Tips for Billing CCM


The challenge of knowing when to bill for CCM shouldn’t discourage physicians from doing so when it’s appropriate. These tips can help physicians determine what patients may qualify for CCM:

1. Capitalize on each patient’s annual wellness visit.

“This is the time when you’re gathering all of that information about the patient,” says Huey. Use this annual visit to assess social, emotional, mental and physical health-related challenges that may have emerged over the course of the last year. One of the goals of CCM is to address these types of challenges, and the annual wellness visit is a perfect time to identify them, she adds.

2. Document risk in the narrative of the note.

Many physicians simply check off a box next to a diagnosis in the electronic medical record without elaborating on what’s happening with the patient—and why he or she needs CCM services. What are the challenges that each patient faces? Why are they at risk of functional decline, acute exacerbation, decompensation, or death?

3. Examine each clinical scenario carefully.

“You need to look at each individual patient’s circumstances and realize that it’s not just about [reporting] a diagnosis code,” says Huey. “It’s also everything related to the patient’s own self-management of the disease.” Don’t assume that every patient with diabetes, for example, needs CCM. Many can manage the disease on their own, she adds.

Think ‘Compliance’ All the time


Although most denials for CCM are technical in nature (e.g., billing for CCM and transitional care management during the same service period or billing for CCM when another provider has already done so), it’s likely that payers performing retrospective audits will begin to examine physician documentation more closely to see whether CCM services are justified. Adhering to all clinical and technical requirements will help physicians bill for CCM appropriately—and retain the revenue they receive, she adds.

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