Hospital readmissions are a significant burden on the healthcare system, both in terms of patient outcomes and financial costs. Chronic diseases, such as diabetes, heart disease, and COPD, are among the leading causes of frequent readmissions.
However, with Chronic Care Management (CCM) programs, healthcare providers can significantly reduce hospital readmission rates by ensuring continuous, coordinated care for chronic patients. This article explores the critical role of CCM in preventing readmissions and how it benefits patients and healthcare systems alike.
What is Chronic Care Management?
Chronic Care Management (CCM) refers to the coordinated services provided to patients who suffer from two or more chronic conditions, which are expected to last at least 12 months or until the patient’s death. These conditions can include diseases like diabetes, hypertension, heart disease, and COPD, which require ongoing medical attention and can significantly impact the patient’s quality of life.
CCM involves the development of a comprehensive care plan that outlines the treatment goals, medications, and strategies for managing these chronic conditions. It requires continuous coordination among various healthcare providers, such as doctors, nurses, and specialists, to ensure that the patient’s care is consistent and holistic. This level of coordination helps to avoid unnecessary hospitalizations, improve the patient’s overall well-being, and reduce healthcare costs.
In addition to care coordination, continuous monitoring of the patient’s health is a critical component. Through regular check-ins and sometimes using Remote Patient Monitoring (RPM), healthcare providers can track the patient’s condition in real time, allowing for early interventions when necessary. The ultimate goal of CCM is to prevent the exacerbation of chronic conditions, improve the patient’s quality of life, and reduce hospital readmissions through proactive and well-organized care.
The Connection Between Chronic Care Management and Hospital Readmissions
The recurring theme in hospital readmissions often stems from gaps in care after patients are discharged. CCM helps fill these gaps by offering continuous monitoring and timely interventions. Let’s look at how CCM directly contributes to preventing hospital readmissions:
- Proactive Care Coordination
CCM ensures that a patient’s healthcare providers, including doctors, nurses, and specialists, stay in constant communication. With RPM integrated into CCM, clinical staff can track vital signs in real time and address concerns before they become critical issues that might necessitate readmission. For example, DrKumo’s RPM technology provides real-time data streaming, allowing healthcare providers to make informed decisions and take swift action when necessary.
- Personalized Care Plans
Each patient’s care plan is tailored to their unique needs. The comprehensive care plan outlines the treatment goals, medical history, medications, and the roles of the patient’s care team members. Such personalization ensures that the patient receives care suited to their condition, minimizing the risk of complications and thereby reducing the chances of a return to the hospital.
- Monitoring Clinical Staff Time and Interaction
One of the critical components of CCM is the regular monitoring of the patient’s condition, even without in-person visits. The clinical staff time spent on non-face-to-face coordination helps maintain continuous oversight of the patient’s health status. This time is reimbursed under Medicare Part via CPT codes and allows healthcare providers to intervene promptly, avoiding the need for hospitalization.
- Reducing Gaps in Post-Discharge Care
Many patients, especially Medicare beneficiaries, experience hospital readmissions due to gaps in care following discharge. CCM services ensure these gaps are minimized by scheduling follow-up care, coordinating medication management, and keeping track of the patient’s overall health through regular touchpoints. The care team’s role in actively managing the patient’s recovery process prevents conditions from worsening.
Chronic Care Management CPT Codes
CCM is essential in reducing hospital readmissions by providing ongoing care to patients with chronic conditions. Medicare reimburses healthcare providers for these services through several CPT codes, each with specific requirements.
- CPT code 99491 refers to “chronic care management services, 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” (83 FR 59577). This code requires that the time spent managing the patient’s care is provided directly by the physician or healthcare professional. Clinical staff time is not included, and 99491 cannot be billed in the same month as other CCM codes like 99487, 99489, or 99490.
- CPT code 99490, in contrast, covers “20 minutes or more of chronic care management services” (83 FR 59687), which can be performed by clinical staff under the direction of a physician. It includes non-face-to-face care coordination for patients with two or more chronic conditions but allows clinical staff time to count towards the required time.
- CPT codes 99487 and 99489 are used for complex Chronic Care Management (CCM) services. As per the CY 2019 PFS final rule (83 FR 59577), these codes share service elements, including “(1) initiating visit, (2) structured recording of patient information using certified EHR technology, (3) 24/7 access to physicians or clinical staff, (4) comprehensive care management, (5) comprehensive care plan, and (6) management of care transitions.” CPT 99487 covers “at least 60 minutes of clinical staff time,” while CPT 99489 adds “another 30 minutes” to complex CCM services. Both codes allow clinical staff time to be counted, unlike CPT 99491, which requires time spent personally by the billing practitioner.
In summary:
- CPT 99491 is for direct physician care (30 minutes).
- CPT 99490 allows clinical staff to manage care (20 minutes).
- CPT 99487 and 99489 are for more complex cases requiring additional clinical time.
These codes ensure proper reimbursement for managing chronic conditions and help prevent readmissions by providing continuous, coordinated care.
Integration of Remote Patient Monitoring in Chronic Care Management
The integration of RPM into CCM plays a crucial role in improving the management of patients with chronic conditions. RPM devices capture real-time patient data, such as blood pressure and glucose levels, enabling healthcare providers to detect and respond to health changes quickly. Combining RPM with CCM allows providers to adjust care plans more proactively, helping prevent exacerbations and reducing hospital readmissions.
Studies emphasize the benefits of proactive care management. For example, a study from Population Health Management evaluated a proactive CCM program in Germany, which resulted in a 6.2% reduction in hospital admissions among patients with chronic conditions, like coronary artery disease and diabetes. The study demonstrated the value of structured and continuous care, particularly for high-risk patients.
Medicare and Federally Qualified Health Centers
RHCs and FQHCs play a crucial role in providing healthcare services to underserved populations. According to CMS, “RHC and FQHC visits generally are face-to-face encounters between a patient and one or more RHC or FQHC practitioners during which time one or more RHC or FQHC qualifying services are furnished.”
In the CY 2018 PFS final rule, Medicare established a payment structure for Chronic Care Management (CCM) services and later expanded this to include Principal Care Management (PCM) services. PCM services involve “comprehensive care management services for a single high-risk disease or complex condition, typically expected to last at least 3 months and may have led to a recent hospitalization, and/or placed the patient at significant risk of death.” Starting January 1, 2021, PCM services can be billed using HCPCS code G0511, which includes “at least 30 minutes of PCM services furnished by physicians or NPPs during a calendar month.”
CMS clarified that RHCs and FQHCs “would also be able to bill the services using HCPCS code G0511, either alone or with other payable services on an RHC or FQHC claim for dates of service on or after January 1, 2021.” The payment rate for HCPCS code G0511 “will be the average of the national non-facility PFS payment rates for the RHC/FQHC care management and general behavioral health codes” (85 FR 50214).
DrKumo’s Role in Chronic Care Management
DrKumo is a leader in digital health solutions, offering real-time Remote Patient Monitoring (RPM) and Disease Management Protocols (DMP). Certified by URAC and recognized in a $1.032 billion VA contract, DrKumo’s platform integrates AI/ML technology to provide continuous health monitoring for patients with chronic conditions. Their FDA-approved devices track key metrics like blood pressure and oxygen levels, helping healthcare providers prevent hospital readmissions. DrKumo ensures secure, HIPAA-compliant data transmission and offers an easy-to-use interface for both patients and providers.
Learn more about DrKumo’s chronic care management.
Takeaways
Preventing hospital readmissions requires more than just reactive healthcare—it demands a coordinated, proactive approach. Through RPM, patients with chronic conditions benefit from personalized care plans, continuous monitoring, and timely interventions. This leads to better health outcomes, reduced readmission rates, and lower overall healthcare costs.
By incorporating remote patient monitoring into the equation, CCM services can become even more effective, ensuring that patients stay healthy and out of the hospital.
For healthcare providers looking to improve patient outcomes and reduce hospital readmissions through Chronic Care Management, DrKumo offers innovative Remote Patient Monitoring solutions tailored to meet the needs of chronic disease management. Contact DrKumo today to learn more about how our platform can help your practice deliver better, continuous care.
Disclaimer: This article is intended for informational purposes only and is aimed at healthcare professionals. Please note that CPT codes mentioned herein are subject to updates and revisions. It is essential to consult the latest guidelines from CMS or relevant authorities to ensure accurate billing and compliance with current regulations.
