About a year ago this time, my colleagues and I at Klio were fielding a lot of inbound interest for the then newly approved chronic care management (CCM) services code. In conversations with primary care physicians, specialists and healthcare administrators alike, there was much excitement around this newly approved code, which went into effect January 1, 2015 and represented an additional source of revenue for providers. I noticed this excitement firsthand as a presenter at the Health Datapalooza in Washington, DC in June 2015 where there were at least three newly launched startups that were taking a bite of this low-hanging fruit.
Under the approved code, clinicians could derive payment of $42.60 per patient per month for remote chronic care management provided to patients. What constituted remote chronic care management was left vaguely defined (part of the problem) and up to the discretion of the physicians. The requirements set forth by Centers for Medicare and Medicaid Services (CMS) were that patients with at last two or more chronic conditions would receive a minimum of 20 minutes of non-face-to-face care per month. It sounded hard to pass up and frankly too good to be true. A year later, very few have been able to take advantage of the new billing code and it has so far turned out that the juice was not worth the squeeze.
Physicians who fell for Chronic Care Management carrot realized that billing for it would require changes to their electronic health record (EHR) and practice management system (PMS) to be able to record the 20 minutes of activity. Use of the CCM code also meant that the same patient could not be billed under some of the other evaluation and management (E&M) codes by any of the other clinicians that they were seeing for the month in which the CCM code was used. Beyond that, clinicians had to get consent from their patients to be able to use this as it represented a 20% uptick in co-payment for the patient who was often confused as to why they were paying for something that they assumed their clinicians were already doing.
Why did CMS lay out such a carrot? Wouldn’t this perpetuate the fee-for-service mindset that they were desperately trying to wean the constituents away from? For a majority of physicians these chronic care management activities were things that they were already doing, so getting recognized and paid for it only seemed fair. But from CMS’s world-view, this was behavior that they wanted to further develop and hence it made sense to provide a carrot for.
However, CMS’s failure was in communicating the clear intent beyond introducing the code and future direction. CMS needed to be upfront in admitting that payment under the code would not result in a positive cash flow; rather, it was meant as a means to raise the standard of chronic care management by recognizing activities that many clinicians were already doing and incentivizing others to catch-up. Lastly, CMS needed to frame the services to make it more palatable to the patient by including clearer language around measurable activities so that patients could compare and see what new value they were getting from their additional co-pay dollars. It remains to be seen whether CMS will make the needed modifications to drive adoption of the new billing code or whether code 99497 will fall by the wayside like so many others before it. Let’s check back in another year.