Many physicians — especially specialists — have questions about which chronic conditions are eligible for between-visit care under Medicare’s Chronic Care Management (CCM) program and what criteria patients must meet to be eligible.
The confusion is understandable: CMS provides examples of common chronic conditions — but not an exhaustive list. Because conditions that are typically acute may sometimes impact patients for a 12+ month period, CMS guidelines offer providers some flexibility.
Patients are eligible for care coordination if they have 2 or more chronic conditions expected to last 12 months or until death. The conditions must “place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline” (CMS CCM Toolkit).
The patient has to have had the chronic condition documented in a visit during the previous year – for example, observed in an Annual Wellness Visit (AWV), Evaluation and Management (E/M) visit, or Initial Preventive Physical Exam (IPPE). When selecting eligible patients, we recommend looking back at 12 months of data to make sure a qualifying visit is present.
Chronic care covers stable and worsening chronic illnesses, as well as conditions posing threats to life or bodily function:
Type of chronic illness
Example of how Chronic Care Management (CCM) can help
Stable, chronic illness
CCM helps patients stay compliant with treatment goals and avoid negative outcomes – for example, helping a patient with controlled diabetes adhere to medication, diet, and exercise recommendations.
Chronic illness with exacerbation, progression, or side effect of treatment
CCM helps slow disease progression – for example, helping a patient with chronic kidney disease avoid end stage renal failure. Or, CCM helps a patient manage the side effects of chemotherapy.
Acute or chronic illness or injury that poses a threat to life or bodily function
CCM helps a patient manage the aftermath of an acute illness – for example, helping a patient with traumatic brain injury (TBI) navigate life after the event.
CMS maintains a Chronic Condition Data Warehouse. Since 2017, CMS has recognized 30 categories of chronic conditions and 40 additional categories of other chronic health, mental health, and potentially disabling conditions.
However, the Medicare CCM program doesn’t explicitly state which conditions count in their billing guidelines. Here are some examples of common chronic conditions reimbursed by the program, organized by specialty area:
Over our years supporting Chronic Care Management (CCM) programs, we’ve compiled a detailed list of thousands of ICD-10 codes for chronic conditions. We’re happy to share that with you.
Specialists often have concerns about managing care for patients with multiple chronic conditions. They don’t want to step on the toes of primary care providers, but they also know that their patients benefit from care coordination overseen by care managers at the specialty practice who have deeper condition-specific training.
Because specialists depend on referring PCPs, they worry about overlap: will both practices try to enroll the same patients in a CCM program, causing confusion for the patient and primary care practice?
In fact, the CCM program is very undersaturated. Very few providers participate (only 3% of relevant providers as of 2021) and those that do often struggle to scale their programs (average median program size of just 41 patients per provider). Because the CCM program is so underpenetrated, there is a very low risk that two practices in the same geographic area will try to enroll the same patient. This situation can be handled by simply unenrolling the patient (and potentially enrolling them in a Principal Care Management (PCM) program at the specialty office).
Most primary care providers appreciate being able to refer their patients to a specialty practice that is able to provide high-quality between-visit care and support for their patients, improving access and outcomes.
I’m happy to answer any questions you might have about common chronic conditions or building a scalable, effective CCM program – whether you are a primary care provider or a specialty practice.
Jamal has 15+ years of experience building profitable operations across multiple industries. During his time at a telecommunications company, he became convinced that enhanced communication between patients and providers is the key to driving better outcomes. At Phamily, Jamal helps primary care and specialty practices develop strategies for high-quality, profitable, highly-scalable care management.
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