January 30, 2018 | Exploring Complex Chronic Care Management

Chronic Care Management programs are increasingly becoming important for many stakeholders in healthcare. For example, patients receive timely care that allows them to take control of their health in a way that empowers their everyday lives. Physicians also have closer ties to their patients and are better suited to make changes to their care plans as needed while healthcare costs are being reduced due to fewer trips to the ER that are often deemed avoidable. As valuable as this service is to many patients with multiple chronic conditions, some need more than the usual 20 minutes of non-face-to-face care. It can be provided under CPT code 99490 called complex care management.

Complex Chronic Care Management

The goal of CCM programs is to provide patients with the resources and tools to manage their chronic conditions as best they can. Yet, some require additional help due to more unstable conditions.

This is why CMS has begun reimbursing healthcare professionals who provide additional services to patients who fall under complex CCM using code 99487.

A patient is deemed “complex” when they have:

  • Two or more chronic conditions
  • At least one of their conditions being unstable or not at goal for treatment
  • At least two risk factors from at least two separate domains

CMS is even going beyond the typical 60 minutes spent with complex patients. Some patients will require more than an hour. Therefore one can bill for an additional 30 minutes with a complex patient, if needed, using code 99489.

Additional time spent with these patients is crucial when their risk factors can vary from clinical diagnoses, physical limitations, and social determinants.

The Need to Diversify

Throughout CMS’ initiative for Chronic Care Management, we have begun to identify patients who need additional care. Now we need to distinguish patients that need a thorough following from ones who need simple guidance. This is where complex CCM comes in.

Our analysis predicts that approximately one-third of patients enrolled in CCM would benefit from the long code. This includes fuller care plans, coordination with providers outside their practice, additional time spent on and with patients, and social services close to our CCM participants.

Patients who need Complex CCM often vary from month to month. Some require more guidance, help and care plan changes during certain months with other months simply needing a follow-up. Being able to assess and know when to intervene is important in managing and maintaining good health.

Our Care Coordinators check for more information during Complex CCM visits.


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