Chronic Care Management CPT 99490

ProvidersChronicCare

What Is Chronic Care Management?

The Centers for Medicare & Medicaid Services (CMS) recognizes care management as a critical component of primary care that contributes to better health and reduced spending.

Beginning January 1, 2015, Medicare pays separately under the Medicare Physician Fee Schedule (PFS) under American Medical Association Current Procedural Terminology (CPT) code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple (2 or more) chronic conditions.

*CPT 99490 copyright 2014 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. For a summary on the Medicare Learning Network® (MLN), refer to the “Medicare Learning Network® Catalog of Products” located at http://www.cms.gov/Outreach-and-Education/

CCM Scope of Service Elements - Highlights

Structured Data Recording

  • Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology

Care Plan

  • Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).
  • Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record.
  • Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service.
  • Share the care plan electronically outside the practice as appropriate.

Access to Care

  • Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.
  • Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

Manage Care

Care management services such as:

  • Systematic assessment of the patient’s medical, functional, and psychosocial needs;
  • System-based approaches to ensure timely receipt of all recommended preventive care services;
  • Medication reconciliation with review of adherence and potential interactions; and
  • Oversight of patient self-management of medications.
  • Manage transitions between and among health care providers and settings, including referrals to other providers, including:
  • Providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities.
  • Coordinate care with home and community-based clinical service providers.

Chronic Care Program Highlights

Patient-Centered

Patient-Centered

Implement and monitor - and revise as needed - provider-guided care plan using clinical, behavioral, and educational measures.

Identify Barriers

Identify Barriers

By identifying barriers, we develop positive health outcomes by addressing healthcare behaviors in both patients and provider.

Care Coordination

Care Coordination

Address communication barriers between care providers and patients utilizing specific behavioral, clinical, and educational principles to encourage change.

Medication Reconciliation

Medication Reconciliation

Medication reconciliation with review of adherence and any interactions; and oversight of patient self-management of medications.

24/7 Care

24/7 Care

Anytime access will support patient’s around the clock - with full EMR including documentation of their progress.

Our Engagement Measures 4-level engagement measure

Using a series of progressive assessment measures, activities, and surveys, our care team will determine each patient's level of engagement with their healthcare and determine a course of training. The 4 levels include:

Level 1

  1. Disengaged.
  2. Individuals are passive and lack confidence.
  3. Health knowledge is low.
  4. Goal orientation is weak.
  5. Adherence is poor.
  6. Their perspective: “My doctor is in charge of my health.”

Level 2

  1. Becoming aware but still struggling.
  2. Individuals have some knowledge, but large gaps remain.
  3. They believe health is largely out of their control, but can set simple goals.
  4. Their perspective: “I could be doing more.”

Level 3

  1. Taking action.
  2. Individuals have the key facts and are building self-management skills.
  3. They strive for best practice behaviors and are goal-oriented.
  4. Their perspective: “I’m part of my health care team.”

Level 4

  1. Maintaining behaviors and pushing further.
  2. Individuals have adopted new behaviors but may struggle in times of stress or change.
  3. Maintaining a healthy lifestyle is a key focus.
  4. Their perspective: “I’m my own advocate.”

Our Core Features

Software

Software

Award-winning platform, gold-standard apps, EHR integration.

Software
Staffing

Staffing

Expand your care team to reach patients beyond your daily schedule.

Staffing
24/7 Care

24/7 Care

Care centers are staffed for your patients, under your orders; supervision.

Care Centers
Compliance

Compliance

Fits ACA measures, HIPAA compliant portals, EHR integration.

Compliance