As of January 1, 2015, Medicare pays for non-face-to-face care coordination services through American Medical Association Current Procedural Terminology (CPT) code 99490. Chronic care management services may be provided via phone or telehealth by a qualified health care professional under the physician’s general supervision.
The service is usually offered as a 20-minute telephone contact once a month. The contact may not be split up into multiple shorter sessions.
An estimation provided by McKesson’s Chronic Care Management Calculator shows that 50 enrolled patients could equate to an additional $25,560 in annual revenue for a practice.1 Each care coordination contact provides an average revenue of $43 per month for the provider.
Physicians are not the only health care professionals who qualify for participation in this program. Advance practice nurses, physician assistants, clinical nurse specialists, and certified nurse midwives are all eligible to bill Medicare for chronic care management services.2 These services can be fulfilled by the provider or performed by an offsite subcontractor.
A pharmacy could subcontract with a group practice to manage all of the chronic care needs of its patients. Under a collaborative practice agreement, the pharmacy could make a larger impact on patient care and help generate revenue for the group practice.
An opportunity exists for consultant pharmacists to step in and offer these care coordination services in providers’ offices, as well. Several companies are already providing assistance to practices for these services.
Because there are several Medicare compliance requirements, chronic care management services are best handled using a team approach that coordinates multiple health care providers, electronic health records (EHR), and online software support.
The US Centers for Medicare and Medicaid Services (CMS) requirements for providers to bill for CPT 99490 include:
- 24-hour access to clinical staff to address urgent needs
- Continuity of care through access to an established care team
- Ongoing care management for all chronic conditions
- Comprehensive, patient-centered health summary and care plan that include all current records from the patient’s providers that is provided to the patient via a paper or electronic copy
- Management of care transitions among all providers and settings using electronic transmission of information including follow-up with at patient after an emergency room or post-discharge transitional care management service
- Coordination with home- and community-based clinical service providers
- Patient and caregiver access with opportunities for caregivers to communicate about patient care using a certified EHR
Regarding 24-hour access to clinical staff, CMS states, “the patient must be provided with a means to make timely contact with health care providers in the practice to address the patient's urgent chronic care needs regardless of the time of day or day of the week.”
Elsewhere, CMS states that the scope of chronic care management services includes “enhanced opportunities for the beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods.”
Based on this information, 24-hour access is not necessarily defined as a phone call.3
Thanks to improvements in technology, consultant pharmacists can subcontract chronic care management services in providers’ offices with the help of online software support. Several software companies are developing technology that would allow pharmacists and patients to connect and upload data such as lab values, daily exercise, goal monitoring, and medication changes instantly.
Provider reimbursement is increasingly being tied to patient outcomes, and pharmacy will soon begin to shift to a performance-based payment model, as well. Pharmacists must stay ahead of this changing payment structure.
Valuable clinical interventions, follow up with patients with chronic conditions, and documentation of interventions are ways for pharmacists to get themselves ahead of the game when it comes to proving their worth. Adherence, immunization, and medication therapy management programs will probably be the first place we will begin to see outcome-associated payment models put into practice.
Chronic care management offers consultant pharmacists one more revenue-building service to offer in physician practices. A pharmacist could not only build and coordinate the program for the practice, but also help to improve outcomes and decrease health care costs.
There is huge potential for chronic care management, as evidenced by the growing number of subcontracting companies popping up. To flex our clinical muscles, we must think outside of the box of normal pharmacist duties and prove that we can improve the health care system.
The community pharmacy is usually a patient’s single point of contact for medication resources. Patients may see many different health care providers, but chances are they only patronize a single pharmacy.
Therefore, it makes sense for the pharmacy to handle the management of care transitions, coordination with home- and community-based clinical service providers, and ongoing chronic care management. Pharmacists can make a difference by providing a model of continuous care through pharmacist-led chronic management services for patients.
Consultant pharmacists can contract with physician offices to provide clinical care coordination services such as chronic care management using a cloud-based software service. A pharmacy consulting firm could effectively provide subcontracting services for many different providers, which would reduce health care costs and improve outcomes for patients with chronic conditions.
1. McKesson. Chronic care management calculator. http://www.mckesson.com/bps/resources/chronic-care-management-calculator/. Accessed February 8, 2016.
2. Medicare Learning Network. Chronic care management services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Accessed February 8, 2016.
3. SPAC International. Chronic care management services. http://spacinternational.com/chronic-care-management-services.php. Accessed February 8, 2016.
Blair Thielemier, PharmD
Blair Green Thielemier, PharmD is an independent consultant pharmacist living in Arkansas with her husband and daughter. Her latest project is the first-ever virtual pharmacy conference, the Elevate Pharmacy Virtual Summit. She is also the founder of Pharmapreneur Academy, an online e-Course and Community where she guides pharmacist-entrepreneurs through the process and barriers of building a pharmacy consulting business. She is the author of How to Build a Pharmacy Consulting Business, a contributing author for Pharmacy Times and guest host on the Pharmacy Podcast. More information about Dr. Thielemier can be found on her website.