Add Chronic Care Management (CCM) and Principal Care Management (PCM) To Your Practice

00:00:00 Hi, it's Dr. Weitz. Thanks so much for joining me for this episode of the private medical practice academy. We all know that doctors are doing a lot of work to take great care of their patients and that you don't always get reimbursed for that work in 2015, the centers for Medicare and Medicaid services, otherwise known as CMS introduced chronic care management,

00:00:23 otherwise known as CCM. And I'm going to refer to it as such because it's a whole mouthful. The purpose of CCM was to give physicians a way to care for their patients with chronic conditions, more effectively as an intended, or perhaps unintended consequence. CCM has offered docs and opportunity to be compensated for the work that they were doing between office visits, including,

00:00:48 but of course not limited to phone calls, education, care coordination, and prior authorizations as a general statement, CCM was geared towards primary care providers. Okay. You're thinking to yourself, but what about us specialists? We also take care of patients with complex chronic conditions. Well, in 2020, CMS rolled out principal care management, otherwise known as PCM.

00:01:18 Today. I'm going to talk to you about both chronic care management, CCM and principal care management PCM, and how they fit into your practice. Let's start with what is chronic care management. CMS defines CCM as care coordination services done outside of the regular office visit for patients who have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient.

00:01:51 In addition, these conditions need to place the patient at significant risk of death, acute exacerbation, or decompensation or functional decline. You can bill for CCM when a physician or a qualified healthcare professional directs your staff to spend at least 20 minutes of non face-to-face clinical time treating the patient per calendar month. The purpose is to manage and coordinate care for eligible Medicare and dual eligible beneficiaries.

00:02:25 With CCM patients have improved access to healthcare professionals with a unique, comprehensive plan focused on their chronic conditions. So one of the obvious benefits is that CCM can make patients feel special. Now, before you start thinking, this is going to increase your workload. Remember what I said earlier, a side benefit of CCM is that CMS is paying you for work that you and your staff were likely to have been doing anyway,

00:02:57 and that you are not getting paid for. The result is that implementing CCM actually improves patient satisfaction. Your practice is reputation and allows you to practice more efficiently and increase your revenue. Are you wondering how much you can increase your revenue by? Well, currently CMS reimburses $42 for providing a minimum of 20 minutes of CCM per patient per month provide 60 minutes of CCM per patient per month.

00:03:32 And your practice will get $117 and 60 cents per patient. Let's say you have a practice with a hundred patients who qualify for CCM. That means that you could earn anywhere from 4,200 to $11,760 per month for work that you're likely to be doing. Anyway. The hardest part of incorporating CCM into your practice is the confusion around CMS coding and billing. So if you're thinking to yourself,

00:04:06 what else is new? I totally understand that learning the coding rules are just not that hard. And as with everything else, it's all about the documentation. So now I'm going to give you an overview of the billing requirements for CCM to start with CMS distinguishes between complex and non-complex care. The key differences between them are this, the amount of time your clinical staff needs to provide the involvement and the work of the billing practitioner and the extent of care planning performed.

00:04:46 Basically, if you feel the care provided is complicated and complex and requires more than 60 minutes a month, it's considered complex. Now, the thing I want you to understand is that regardless of whether you bill for non-complex or complex care, you need to have a minimum of two ICD tens listed. Remember when I was telling you that they have to have a minimum of two chronic conditions,

00:05:15 this is why you're going to need at least two ICD tens that fit the criteria non-complex care is built in 20 minute increments of clinical staff, time up to a total of 60 minutes in a month. The first 20 minutes is paid at $42. The second and third, 20 minute increments are paid at $37 and 80 cents. Each in comparison, complex care is paid at $93 for the first 60 minutes,

00:05:49 and then $46 and 49 cents for an additional 30 minutes. If your clinical is spending 90 minutes per month, then you would collect $139 and 49 cents per patient. Now at first blush, you may be thinking, wait, I'm not making significantly more money taking care of complex patients, but here's the key difference with complex care. There is no limit on the number of additional 30 minute increments you can charge per month.

00:06:22 So if you have a complex patient that your clinical staff is spending a huge amount of time, coordinating the care for there is no limit on your ability to bill for this time. Now, in order to incorporate CCM into your practice, you're going to need to develop processes for implementation, tracking and billing tracking time. And then using the appropriate codes is probably the most difficult part of this.

00:06:50 Start by having a conversation with your billers. Now, there are certainly software solutions that can automatically adjust the corresponding codes required. When a patient has reached the various time increments of care, these companies can help you streamline CCM, but in reality, you need to understand the processes before you decide to use a company. It is going to be up to you to make the clinical decision as to whether this patient is actually sick enough to warrant CCM,

00:07:23 whether they're qualified for complex or non-complex, and then ultimately you will need to provide the documentation that the billers are going to use. And that's true, whether you do in-house billing or you use a company that helps you streamline CCM. Now let's turn our attention to what is principal care management. Otherwise known as PCM PCM is similar to CCM because both are services that are intended for patients requiring ongoing clinical monitoring and care coordination.

00:08:00 One of the key differences, however, is that PCM only requires patients to have one complex chronic condition. Typically, as I said before, CCM is provided by primary care. PCM is often provided by specialists, but could be provided by a primary care physician as well. There are six basic criteria for PCM. The first is that the condition is expected to last,

00:08:29 at least three months. Second, that the condition places, the patient at significant risk of hospitalization, acute exacerbation, or decompensation functional decline or death, third, the condition requires the development monitoring or revision of a disease specific care plan. Fourth, the condition requires frequent adjustments in medication regimens and or the management of this condition is unusually complex because of the patient's comorbidities.

00:09:06 Fifth, the condition requires ongoing communication and care coordination between the relevant providers who are involved in the patient's care. And then six that the condition requires at least 30 minutes of PCM services per calendar month. More likely than not. You're already providing care for these complex Medicare patients. The key to getting reimbursed for providing this care is to document the details of the disease specific care plans,

00:09:38 the adjustments in your medication regimens, the ongoing communications with specialists and basically care coordination. Just like with CCM. It's very important to choose the right patients for PCM. Not every patient with a complex chronic condition requires PCM. The whole idea is that the condition must be severe or unstable enough that the patient was recently repeatedly hospitalized for it, or is at risk for imminently being hospitalized.

00:10:13 The basic idea is they're paying you for either CCM or PCM with the hopes of keeping people out of the hospital and therefore saving money. So one of my favorite terms is stable, unstable. We all know patients who are what I would describe to you as a mess. They're sick. They have multiple comorbidities, but as sick as they are as many co-morbidities that they have,

00:10:45 they're still relatively stable. They're not about to go to the hospital. They haven't been in and out of the hospital. They're basically stable EMS. That patient who has a well controlled chronic condition does not meet the criteria for PCM. Just like with CCM. It is very important that you and your billers use the right CPT codes to bill for PCM. And it's essential to document the name of the staff member.

00:11:14 The time spent what they did specifically and their credentials. The good news is that many of the EMR EHRs are set up to facilitate this. As I said before, talk to your billing folks and your EMR vendor to develop a process from there, you can decide whether you have the tools needed to bill for PCM or for CCM for that matter. Or do you need to add an integrated additional solution to facilitate this?

00:11:46 The last point I want to make to you is that you need to obtain consent from the patient. Why is that? Well, because they're responsible for the co-insurance. You're going to want to develop the talking points to explain CCM and or PCM to your patient so that they understand these programs. You want to communicate to them, that the goal of the program is to improve the quality of care that they receive.

00:12:13 If you do this, you're not going to meet much resistance. These programs are really designed for the patient's best interest. The fact that you will actually be compensated for the work that you're doing anyway is just an added bonus to your practice. Please be sure to sign up for my newsletter below, I'll be sending you tips on how to start a practice,

00:12:35 grow a practice, and then to add multiple services so that you can maximize your revenue.