Chronic Care Management: How Physicians Can Increase Practice Revenue without Seeing More Patients

Dr. Seth Flam
Dr. Seth Flam

Guest post by Dr. Seth Flam, board certified in Family Practice and co-founder and CEO of HealthFusion.

CMS has some good re-imbursement news for primary care physicians for 2015: It has announced a new chronic care management program starting January 1 that will allow providers to bill for providing care management for patients with chronic conditions.

In other words, primary care providers can get paid for care they likely already provide.

With this new program, chronic care management can provide a good source of revenue for a practice, if designed, managed and billed correctly. Since a provider can bill $42.60 per patient per month, with a reasonable number of patients with chronic conditions in the practice, a provider can easily see revenue of more than $50,000 per year.

Annually: $511.20 per year per patient X 100 patients = $51,120 per year

(Assumes the provider bills for each patient 12 months out of the year)

But—there are very specific things providers need to know about the program, and particular requirements they need to follow in order to get paid. Here is a preview of some of the requirements:

  1. Identify chronic care patients who qualify.
  2. Eligible patients include those with two or more chronic conditions expected to last at least 12 months, or until death, that place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.
  3. Only one provider can bill for the chronic care management code for a patient in a 30-day period.
  4. The billing provider must have a signed agreement with the patient allowing them to bill for these services and detailing cancellation rights, co-payments and types of services.
  5. Among other things, the provider needs to supply 20 minutes or more of chronic care management services per patient per 30 day billing period.
  6. The provider will need to create a patient-centered care plan document compatible with the patient’s choices and values.
  7. The provider must provide either a written or electronic copy of the care plan to the patient.
  8. The provider will need to manage care transitions between and among health care providers and settings.
  9. Bill in accordance with CMS requirements using CPT code 99490, making sure the practice’s EHR software provides the information needed to manage and bill for this program.
  10. Begin the process of establishing practice processes and gathering patient agreements soon, although the program doesn’t go into effect until 2015.

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