Julie C. Jacobson Vann, PhD, MS, RN Managing Care Solutions November 2015

Traditionally, the Medicare fee-for-service program was not structured to address chronic health conditions.  The program has not historically reimbursed primary and tertiary preventive services to a great extent, such as  care management and health coaching and other lifestyle-related preventive services (Thorpe, 2012).  In 2013, CMS released a fee schedule that included two new billing codes, CPT codes 99495 and 99496, to reimburse care providers for transitional care management services (Centers for Medicare & Medicaid Services [CMS], 2013).  This was an important but insufficient step to address the health needs of Medicare beneficiaries with chronic illnesses.

More recently, primary care providers and some specialists have a new opportunity to increase clinical revenue while improving self-management, health outcomes and patient satisfaction for Medicare Fee-For-Service (FFS) beneficiaries with two or more chronic conditions.  This new initiative, Chronic Care Management (CCM) services, has been reimbursable through Medicare since January 1, 2015 (MLN, 2015a).  The CCM service — billable via CPT code 99490 — allows providers to bill for and obtain reimbursement for helping patients manage their conditions between office visits, for example, by using telephone outreach for a minimum of 20 minutes per month.  Practices now have the opportunity to obtain reimbursement for care management and population health services that are often provided to patients without compensation.

Now, using CPT code 99490, practices have an opportunity to get reimbursed for care management services that they provide to fee-for-service Medicare patients with two or more chronic conditions.

The Need for Chronic Care Management Services

Improving care delivery and outcomes for persons with chronic illnesses is a high priority for the Centers for Medicare & Medicaid Services (CMS; Miller, 2015).  Chronic conditions are a CMS focus because of their high prevalence and related death rates, substantial health service delivery costs, and burden on patients and health systems.  In addition, chronic conditions are generally amenable to interventions that prevent complications, reduce unnecessary health care costs and utilization, and improve self-care and health status.

Common Chronic Conditions among Medicare Beneficiaries

Fifteen chronic conditions that are common among Medicare beneficiaries and were used to define multiple chronic conditions by the Department of Health and Human Services Strategic Framework on Multiple Chronic Conditions are listed in the table below.  These and other chronic conditions are the target of Medicare’s CCM initiative.

15 Common Chronic Conditions Used to Define Multiple Chronic Conditions

High blood pressure

High cholesterol

Ischemic heart disease



Heart failure

Chronic kidney disease


Chronic obstructive pulmonary disease (COPD)

Alzheimer’s disease

Atrial fibrillation





Source:  Centers for Medicare & Medicaid Services, 2012

Prevalence of Chronic Conditions among Medicare Beneficiaries

Chronic diseases and conditions are now the most common health problems in the United States (National Center for Chronic Disease Prevention and Health Promotion [NCCDPHP], 2015).  Among the 31 million persons enrolled in FFS Medicare in 2010, 68.4 percent (> 21 million) had two or more chronic conditions and 36.4 percent had four or more chronic conditions (Lochner & Cox, 2013).  High blood pressure (58 percent) was the most common chronic condition among FFS Medicare beneficiaries in 2010, followed by high cholesterol (45 percent), ischemic heart disease (31 percent), and arthritis (29 percent; CMS, 2012).

Percentage of FFS Medicare Beneficiaries with the Top 10 Chronic Conditions

High blood pressure

High cholesterol

Ischemic heart disease



Heart failure

Chronic kidney disease


Chronic obstructive pulmonary disease

Alzheimer’s disease











Centers for Medicare & Medicaid Services, 2012

Mortality Rates Associated with Chronic Conditions

Of the top 10 causes of death among older adults, most are chronic diseases (Heron, 2015).  The trend for major causes of death shifts throughout the lifespan, with unintentional injuries leading the list from ages 1 to 44 years.  In persons 45 to 64 years of age, cancer (31.7 percent) is the leading cause of death.  Heart disease then moves to the leading cause of death in persons 65 years and older (Heron, 2015).  Heart disease and cancer account for almost half of deaths among persons 65 years and older (Centers for Disease Control and Prevention [CDC], 2015a).

Leading Causes of Death –

Ages 65 and Older

Leading Causes of Death –

Ages 85 and Older

Heart disease


Chronic lower respiratory diseases


Alzheimer’s disease


Unintentional injuries

Influenza and pneumonia

Kidney disease












Heart disease


Alzheimer’s disease


Chronic lower respiratory diseases

Influenza and pneumonia

Unintentional injuries


Kidney disease












Heron, 2015

Health Services Utilization and Costs of Chronic Conditions
Health Services Utilization among Medicare Beneficiaries

Health services utilization is highest among Medicare beneficiaries with multiple chronic conditions.  For example, approximately 20 percent of all Medicare beneficiaries were hospitalized during 2010, compared with 60 percent of persons with six or more chronic conditions (CMS, 2012).  As the number of chronic conditions increases the proportion of persons being hospitalized increases, as does the number of hospitalizations per person (CMS, 2012).  This also holds true for emergency department (ED) visits.  Among Medicare beneficiaries with zero or one chronic condition, 14 percent had one or more ED visits; however, for persons with six or more chronic conditions, 70 percent had an ED visit during 2010 (CSM, 2012).

Health Care Expenditures in the U.S.

The United States spent approximately $2.9 trillion on health care services in 2013 (CDC, 2015b).  Medicare’s share of spending in 2014 was $597 billion (H.J. Kaiser Family Foundation, 2015).  Approximately 86 percent of US health care expenditures overall are attributable to care delivered to persons with chronic conditions (CDC, 2015b), including coronary artery disease, diabetes, congestive heart failure, and chronic obstructive pulmonary disease (Vogeli, 2007).  For Medicare beneficiaries, 90 percent of expenditures has been attributed to persons with one or more chronic conditions (Thorpe, 2012).

Out-of-Pocket Health Care Expenditures for Medicare Beneficiaries

Out-of-pocket health care expenditures pose a huge financial burden for Medicare beneficiaries, especially for those who are older and those in poor health (Cubanski, 2014).  These out-of-pocket costs include copayments and deductibles, non-covered services, and monthly premiums.  Approximately half of the 54 million persons enrolled in Medicare during 2013 had incomes less than $23,500 (Cubanski, 2014).  Yet, the 2010 average out-of-pocket health spending was $1,926 for persons 65 to 74 years and $5,962 per persons 85 years and older (Cubanski, 2014).  Out-of-pocket health expenditures are also higher for persons with chronic conditions and functional impairments, persons with activities of daily living (ADL) limitations, and persons who have been hospitalized, when compared with persons who do not have these circumstances.

Out-of-pocket health care costs for Medicare beneficiaries with specific conditions or circumstances – 2010
Self-report of poor health

Self-report of excellent health


3 or more ADL limitations

No ADL or IADL limitations


Alzheimer’s disease

Parkinson’s disease

End stage renal disease










Cubanski, 2014

Quality of Life among Persons with Chronic Conditions

Chronic conditions can also adversely affect the quality of life of patients and their families.

Dimensions of Quality of Life that May be Affected by Chronic Illnesses
Physical functioning


Bodily pain

General health


Social functioning

Role – emotional

Mental health

Juenger et al., 2002

Health Behaviors Associated with Chronic Conditions and Deaths

Chronic conditions and their complications are largely preventable.  In fact, a large proportion of chronic diseases and associated suffering, early deaths, and costs have been attributed to four unhealthy behaviors that can be modified:  lack of physical activity, poor nutrition, tobacco use, and drinking too much alcohol (CDC, 2015a).  Recent studies have indicated the following poor health behaviors among US adults, age 18 years and older:

  • 52% did not meet the recommended levels of aerobic physical activity
  • 76% did not meet recommendations for muscle-strengthening physical activity
  • 38% ate fruit less than once a day
  • 23% ate vegetables less than once a day
  • Almost 20% smoked cigarettes
  • Approximately 18% binge drink an average of 4 times per month – consuming an average of 8 drinks per binge

Obesity is a major health concern in the U.S., with 34.9 percent or 78.6 million adults being obese and 69 percent being obese or overweight (CDC, 2015c; Trust for America’s Health, 2015; CDC, 2014).  Obesity is associated with problems such as heart disease, stroke, type 2 diabetes, some types of cancer and orthopedic problems.

In the U.S.:

More than 480,000 deaths per year are attributed to smoking cigarettes.

Approximately 88,000 deaths per year are attributed to drinking too much alcohol.

CDC, 2015a

Financial Burden of Poor Health Behaviors in the U.S.

Poor health behaviors are costly.  For example, the estimated medical costs of obesity in 2008 were $147 billion (CDC, 2015a).  The estimated costs associated with smoking are $289 billion per year; and costs associated with drinking too much alcohol are $223.5 billion a year (CDC, 2015a).  One study of non-institutional adults concluded that health care expenditures for inactive adults is $1,437 more per year than for active adults (Carlson et al., 2015).


Benefits of Chronic Care Management and Preventive Services

Chronic care management services are known to address some of the health and financial burdens associated with chronic illnesses for society and individuals.  The Chronic Care Model defines the care delivery system components that support care delivery for patients with chronic illnesses.  Several of these components or services have been incorporated into Medicare’s CCM service, such as self-management support and clinical information systems to enhance self-care, care coordination, and communication (Bodenheimer, Wagner & Grumbach, 2002a).

The benefits of chronic care management services have been described in a number of studies.  One large study of telephone care management services demonstrated success in improving patient satisfaction and communication with care providers, enhancing self-management skills, increasing use of preventive services, and decreasing hospitalizations and medical costs (Wennberg et al., 2010).  A review 39 studies involving implementation of components of the chronic care model reported that in 32 studies the interventions were associated with at least one improved process or outcome measure for persons with diabetes (Bodenheimer, Wagner, & Grumbach, 2002b).  Examples of observed outcomes include improved HbA1c levels, reduced hospital and outpatient use, and reduced length of hospital stays.  In a study of patients with asthma, the chronic care intervention program was associated with a decrease in emergency department visits (Bodenheimer et al., 2002b).

The new Medicare CCM initiative mirrors some of the services that were found to be effective in Medicare Advantage plans, such as an initial in-person visit to conduct a detailed health risk appraisal, such as the Medicare annual wellness visit, development of individualized care plans, medication management, and a call-line with trained nurses to provide health coaching (Thorpe, 2012).


Medicare’s Chronic Care Management Program

Purpose and Goals of Medicare’s CCM Program

The purpose of Medicare’s Chronic Care Management program is to help patients with chronic conditions better manage their self-care and optimize their health.  The primary goals of CCM are to assist patients with:

  • accessing needed health services
  • coordinating care
  • enhancing their self-management skills, health behaviors, and compliance with their plan of care
  • maintaining health and functioning

An additional expected benefit of CCM is to reduce unnecessary utilization of health services and reduce associated costs.  And an important benefit for care providers is the opportunity to get paid for managing the care of patients with chronic illnesses between office visits, a service that has traditionally gone uncompensated.  This also helps to reduce some of the disparities in compensation between primary care providers and specialists (Peckham, 2015; Sandy et al., 2009).

It is expected the CCM goals will be achieved through enhanced opportunities for communication, coordination between providers, and identifying and incorporating patient preferences, priorities, and goals into a patient-centered plan of care.

Medicare Coverage for CCM Services
Patient Eligibility for Chronic Care Management Services

Medicare beneficiaries are eligible to receive CCM services if they have two or more chronic conditions that are expected to last at least 12 months or until the patient dies.  These conditions would be expected to place the patient at risk for death, acute exacerbation or decompensation, or functional decline (Medicare Learning Network, 2015).  Coverage is available for beneficiaries in fee-for-service Medicare.  The CCM program is not available to Medicare Advantage Plans, Rural Health Clinics, and Federally Qualified Health Centers (FQHCs).

The CCM billing code (99490) cannot be billed during same service period as:

  • Transitional care management: CPT codes 99495-99496
  • Home health care supervision or hospice care supervision: HCPCS codes G0181-G0182
  • End stage renal disease services: CPT codes 90951-90970
Provider Eligibility for Chronic Care Management Services

The CCM services can be provided and billed by primary care physicians, some physician specialists, physician assistants, and advanced practice registered nurses, including nurse practitioners, clinical nurse specialists, and certified nurse midwives.  The primary clinician that bills for CCM is responsible to oversee the services, however can delegate the data collection and care coordination activities to other clinical staff, either employed by the clinical setting or provided by a qualified subcontracting agency.  Only one care provider can bill for CCM per beneficiary per calendar month.

Medicare Copayments and Deductibles for CCM Services

Medicare beneficiaries are responsible for deductibles and copayments for CCM services, similarly to office visits.  If the beneficiary has a Medicare supplemental insurance or MediGap policy, the deductibles and copayments may be partially or fully covered.  The estimated copayment amount is $8 per month.

Patient Enrollment in CCM Services

Patients must voluntarily enroll in the CCM program and agree, in writing, before a clinician can charge for care coordination services.  The CCM services must be initiated by the billing provider during:

  • A comprehensive Evaluation and Management (E & M) visit
  • Medicare Annual wellness visit (AWV), or
  • Medicare Initial preventive physical examination (IPPE)

Often it is most efficient to initiate the informed consent and enrollment process for CCM services during an IPPE or Initial or Subsequent AWV.

Components of the CCM Program

Nine requirements must be met for the care provider to bill for CCM services:

  • Informed consent
  • Care management
  • Electronic health record
  • Patient-centered care plan
  • Access to care
  • Continuity of care
  • Communication
  • Manage care transitions
  • Coordinate care with home and community-based providers
Informed Consent

The care provider who will bill for and oversee CCM services for a patient must obtain written informed consent from the eligible Medicare beneficiary.  This consent must be obtained during an eligible visit, such as the IPPE or AWV.  Informed consent cannot be obtained by calling patients to recruit them for the CCM services or by mailing them a consent form.

CCM Informed Consent Requirements – Written and Verbal Discussion
Care provider informs the patient about:

The CCM services

How to access CCM services

Sharing of health and medical information with other care providers electronically

Beneficiary cost-sharing:  coinsurance and deductibles

CCM being delivered by only 1 care provider at a time for the patient

How to stop or revoke the CCM service

Care Management

The care team must provide at least 20 minutes of non-face-to-face care management services during the billing calendar month, with an emphasis on helping the patient manage chronic conditions.  These services should also focus on assessing the patient’s complete health needs, planning for preventive services, conducting medication reconciliation, and monitoring and improving self-management of medications as needed.

The non-face-to-face communication does not have to be provided by the billing clinician.  This can be provided by clinical support staff employed by the clinical site or provided by a subcontracting agency.

Manage Care Transitions

The care team must support patient transitions between care settings.  This includes following up with patients after an emergency department visit or discharge from a hospital or other care setting.  Offering and providing this support to patients when they move between care settings is important for improving continuity of care, verifying the patient’s understanding of plans of care, clarifying self-care instructions, and coordinating referrals with other care providers.

Note:  CCM cannot be billed during the same month that transitional care management services (CPT codes 99495-99496) are billed.

Coordinate Care with Home & Community-Based Service Providers

The care team must coordinate with home and community-based service providers to help address the patient’s psychosocial needs and functional deficits.  For example, this may involve communicating and coordinating with:  home health agencies, hospice services, outpatient therapies, durable medical equipment suppliers, transportation services, nutrition counseling, and programs that promote physical activity, such as Cancer Fit programs.  Coordination of care must be documented in the patient’s medical record.

Develop a Patient-Centered Care Plan

The care team must develop a patient-centered care plan that extends beyond a medically-focused treatment plan to include physical, mental, cognitive, psychosocial, functional, and environmental needs.  To be patient-centered, the care plan should incorporate the individualized expressed needs, values, beliefs, preferences and choices of the patient (Rodak, 2012; Shaller, 2007; Wolf et al., 2008).  Ideally this care plan should be developed collaboratively between the patient and/or family and care provider.  One approach for identifying the individualized needs and preferences of the patient is to create a structured tool and communication process that is used by a telephonic care manager or clinic staff member to collect this information.  This information can be incorporated into the care plan and used by the clinician to individualize the plan of care.

Examples of Components of a Patient-Centered Care Plan
Patient information – demographic data

Emergency contact information

Health care providers and agencies involved in care

Plans to coordinate with other services and agencies

Diagnoses, medications and allergies

Health problems, goals, plans & intended actions

Living arrangements

Language preference

Dietary needs

End-of-life care decision-making

Symptoms that are most concerning to the patient

Barriers to improving health and health behaviors

Self-care strengths

Individualized health and wellness goals focused on:  physical activity; medication management; self-management; safety; other health behaviors

The care plan must be provided to the patient in writing or electronically.  And it must be shared with collaborating providers of care.

An important concept to patient-centered care is including the patient as a partner in his or her own care (Shaller, 2007).  Several identified benefits of patient-centered approaches include improved patient satisfaction, perceived quality of care (Wolf, 2008), adherence to plans of care, and health outcomes (Robinson et al., 2008).

Continuity of Care

The patient should be provided with access to a designated care provider who sees the patient for successive routine appointments.  One potential benefit of continuity of care is a reduction in ambulatory care-sensitive hospitalizations (Menec et al., 2006).  In addition, continuity of care has been linked to higher patient satisfaction levels (Saultz & Albedaiwi, 2004).

Electronic Health Record

The care team must use certified electronic health record technology for documenting and transmitting information to meet several of the requirements of the CCM services.  For example, the EHR must be used to:

  • Document demographics, problems, medications & medication allergies
  • Create a summary of care
  • Electronically transmit a care summary to other providers for purposes of coordinating care
  • Document CCM consent
Access to Care

The care team must provide access to care for beneficiaries 24 hours a day, 7 days a week for the enrolled patient’s acute or urgent chronic care needs.


The care team must provide enrolled CCM patients with enhanced opportunities to communicate with the clinician or care team by telephone and through asynchronous approaches, such as secure messaging through a patient portal.



Medicare’s new CCM service is a great opportunity for primary care providers to improve care delivery and satisfaction for beneficiaries with chronic illnesses while increasing clinical revenues. It has been estimated that with the support of registered nurses to conduct many components of CCM, a practice could earn $332 per enrolled patient per year (Basu et al., 2015).  This increases to approximately $385 per enrolled patient per year if the CCM services are delivered by a trained medical assistant (Basu et al., 2015). With an estimated 68.4 percent of FFS Medicare beneficiaries having two or more chronic conditions, this could be a relatively large boost to the clinic’s income (Lochner & Cox, 2013).

The components of Medicare’s CCM service may seem daunting in a primary clinical practice that may already be working to address the needs of patients while juggling and meeting documentation and multiple performance management initiatives. The Chronic Care Management team at Managing Care Solutions has expertise and experience in developing and delivering successful care management initiatives aimed at improving care and outcomes for both Medicare and Medicaid beneficiaries. Our team has experience with implementing initiatives while minimizing the burden to practice by integrating our initiatives into the existing practice workflow.

Get in touch today to discuss implementing a CCM program at your practice.  

Abbreviations and Acronyms

AWV Annual Wellness Visit
CCM Chronic Care Management
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
FFS Fee-For-Service
IPPE Initial Preventive Physical Examination


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