Engaging Patients Through Care Management Services

Care management services are designed to engage patients as active partners in their healthcare so they can effectively manage their complex medical conditions. These programs can lead to improved clinical outcomes, enhanced patient experiences, reduced costs of care, and less duplication of services. It is critical to identify patients with cancer who can benefit from these services as early as possible so they can be guided toward evidence-based treatments before they go too far down a costly path that may jeopardize outcomes.¹

Who Are the Members of the Care Management Team?

Care management programs require a team-based, patient-centered approach to healthcare that focuses on both the physical and mental well-being of the individual. Oncology care managers are key members of the team. Typically, these are highly skilled nurses who help patients with cancer navigate the complex nature of their disease. They act as liaisons—coordinating care between providers, community resources, and insurance companies, which ensures prompt communication regarding the patient’s health within and outside the practice. Oncology care managers also address patient concerns, offer education on the management of symptoms and treatment-related adverse events, and help with issues related to clinical trials, financial assistance, and end-of-life decisions. They walk side-by-side with patients (and their families) throughout the cancer treatment journey, which allows patients to focus on their health and quality-of-life goals.

Additional members of the care management team may include other professionals, such as medical providers, social workers, community health workers, dieticians, and pharmacists, who all work together to meet the needs of patients and ensure they understand their treatment options.¹

Types of Care Management Services Available

The Centers for Medicare & Medicaid Services (CMS) recognized the benefit of care management services and began paying for Chronic Care Management (CCM) in 2015 under the Physician Fee Schedule for patients with multiple chronic conditions.² In 2020, CMS expanded these services by creating Principal Care Management (PCM) services for patients with a single chronic condition or for providers treating patients for only one of their chronic conditions.

CCM and PCM services require an initial visit, patient consent, use of certified electronic health record technology, a comprehensive care plan, access and continuity of care, comprehensive care management, and transition management.²

Chronic Care Management

CCM is care coordination that is outside of the regular office visit for a patient with multiple (2 or more) chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk for death, acute exacerbation or decompensation, or functional decline. Providers may bill for CCM services for a calendar month when at least 20 minutes of non–face-to-face clinical staff time, directed by a physician or other qualified healthcare professional, is spent on activities to manage and coordinate care for eligible patients.²

Complex CCM services require and include moderate-to-high complexity medical decision-making by the physician or other billing provider.³

Principal Care Management

The requirements for PCM are very similar to the requirements for CCM. However, PCM services are for a single high-risk disease that is expected to last at least 3 months and that places the patient at significant risk for hospitalization, acute exacerbation/decompensation, functional decline, or death.³ PCM requires the development, monitoring, or revision of a disease-specific care plan. The condition is unusually complex due to comorbidities and requires ongoing communication and care coordination between relevant practitioners who are furnishing care.³

Transitional Care Management

Transitional Care Management (TCM) services are provided for patients who are discharged from an inpatient stay for a 30-day period, which begins when the patient is discharged and continues for the next 29 days. These services reduce readmission rates, improve clinical outcomes, and engage patients and caregivers through education and coordination of care. TCM services require moderate or high medical decision-making for patients with medical or psychosocial problems.⁴ There must be interactive contact with the patient or caregiver (by phone, e-mail, or face-to-face) within 2 business days of the patient’s discharge. At least 2 attempts to reach the patient must be made; however, Medicare indicates that attempts to reach the patient should continue until successful. If providers are unable to reach the patient after 2 or more attempts, they may report TCM services if the attempts to communicate are documented in the medical records and all other requirements are met.

The provider and clinical staff (as appropriate under the provider’s direction) must provide patients with medically reasonable and necessary non–face-to-face services within the 30-day TCM service period.⁴ A face-to-face visit must also be provided within 7 or 14 days, dependent on medical complexity.

Coding for Care Management Services

The following Current Procedural Terminology (CPT) codes describe care management services and may be reimbursed by Medicare and some other payers. It is important to check individual payer reimbursement care management policies.^2-4

• CPT code 99424. PCM services, for a single high-risk disease, first 30 minutes provided personally by a physician or other qualified healthcare professional, per calendar month
• CPT code 99425. PCM services, for a single high-risk disease, each additional 30 minutes provided personally by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure)
• CPT code 99426. PCM services, for a single high-risk disease, first 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
• CPT code 99427. PCM services, for a single high-risk disease, each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure)
• CPT code 99437. CCM services, multiple (2 or more) chronic conditions, each additional 30 minutes by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure)
• CPT code 99439. CCM services, each additional 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
• CPT code 99487. Complex CCM services, multiple (2 or more) chronic conditions, moderate-or-high complexity medical decision-making, first 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
• CPT code 99489. Complex CCM services, multiple (2 or more) chronic conditions, each additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month (list separately in addition to code for primary procedure)
• CPT code 99490. CCM services, multiple (2 or more) chronic conditions, first 20 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month
• CPT code 99491. CCM services, multiple (2 or more) chronic conditions, provided personally by a physician or other qualified healthcare professional, at least 30 minutes of physician or other qualified healthcare professional time, per calendar month
• CPT code 99495. TCM services with moderate medical decision complexity (face-to-face visit within 14 days of discharge)
• CPT code 99496. TCM services with high medical decision complexity (face-to-face visit within 7 days of discharge)

Conclusions

Care management services not only help individuals achieve optimal health status for their chronic conditions, but they also reduce healthcare costs and improve the overall patient experience. Patients enrolled in care management programs take an active role in managing their disease, setting goals, and focusing on what is important to them, which helps them gain a better understanding of their condition and a sense of control. Care managers provide valuable information to patients and their caregivers and facilitate smooth communication between the patient and the healthcare team. They advocate for what is best for the patient and build trust between the patient, caregiver, and healthcare team.

References

1. Optum. Strategies for better managing the unpredictable and accelerating cost of cancer care. May 22, 2015. www.optum.com/content/dam/optum/resources/whitePapers/strategies-for-managing-the-unpredictable.pdf. Accessed November 15, 2022.
2. Centers for Medicare & Medicaid Services. Connected care toolkit: chronic care management resources for health care professionals and communities. Updated May 2022. www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/CCM-Toolkit-Updated-Combined-508.pdf. Accessed November 14, 2022.
3. Centers for Medicare & Medicaid Services. Chronic care management services. September 2022. www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf. Accessed November 17, 2022.
4. Centers for Medicare & Medicaid Services. Transitional care management services. www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/transitional-care-management-services-fact-sheet-icn908628.pdf. Accessed November 16, 2022.

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