Medicaid Payment and Reimbursement

Managing Transitional and Chronic Care Profitably: A Guide for Hospital-Owned Physician Practices

April 5, 2017 11:21 am

Transitional care and chronic care management programs provide revenue opportunities for hospital-owned practices that are well prepared to implement them.

The Affordable Care Act (ACA) includes a number of key initiatives designed to improve chronic care coordination and transitional care for people with chronic conditions. Although a repeal effort is now well underway, these programs are likely to remain in place because they reflect the industry’s overall focus on improving value, which will likely survive any replacement legislation. These initiatives therefore are likely to continue to provide revenue opportunities for hospital-owned physician practices.

Starting in January 2013, the Centers for Medicare & Medicaid Services (CMS) began paying physicians and non-physician practitioners for transitional care management (TCM) services following an inpatient admission for any patient who meets specific coverage criteria established by CMS under two CPT codes: 99495 and 99496. TCM involves a range of specified services to support a patient for 30 days following his or her discharge from a facility setting. a As of Jan. 1, 2017, CMS pays the same providers for chronic care management (CCM) under CPT code 99490, 99487, 99489 and G0506. CCM supports a patient with two or more chronic conditions through non-face-to-face care management services. b  

Developing and implementing successful TCM and CCM programs requires a team approach involving all levels of staffing to meet the challenges presented by documenting and coding for care management services. The regulatory requirements for providing and billing TCM and CCM are significantly different from the rules for other services furnished by physicians and non-physician practitioners, such as evaluation and management services and procedures, but the new reimbursable codes are incentives for hospital-owned practices to implement TCM and CCM into their practices. In 2017, the fees for these services are:

  • CCM (code 99490): $42.71
  • Complex CCM (code 99487): $93.67
  • Complex CCM Add On (code 99489): $47.01
  • TCM (14 days) (code 99495): $165.45
  • TCM (7 days) (code 99496): $233.99

Chronic Care Management

In 2014, two-thirds of Medicare beneficiaries had multiple chronic conditions and accounted for 94 percent of Medicare spending. c According to statistics from the Centers for Disease Control and Prevention more than 133 million Americans—one-third of the total population—suffer from at least one chronic disease, and 70 percent of deaths result from chronic diseases. d

CCM services may be billed separately and concurrently with face-to-face encounters such as wellness and acute care visits. CCM is intended for use by the practitioners who provide the majority of care coordination—typically primary care physicians. However, certain specialists may be able to deliver the services needed to qualify to bill the CCM codes.

CCM services require at least 20 minutes of clinical staff time (per calendar month) directed by a physician or other qualified healthcare professional (assumes 15 minutes of billing provider work per month). Complex CCM requires at least 60 minutes of clinical staff time (per calendar month) directed by a physician or other qualified healthcare professional (assumes 26 minutes of billing provider work per month). In addition, there is a Complex CCM Add on for each additional 30 minutes of clinical staff time work (assumes 13 minutes of billing provider work). All CCM services have the following required elements:

  • Two or more chronic conditions expected to last at least 12 months, or until the death of the patient
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
  • A comprehensive care plan established, implemented, revised, or monitored

To be eligible for CCM, a patient must have two or more significant chronic conditions expected to last at least 12 months. CMS has not specified what diagnosis codes should be reported as part of CCM claims. Absent guidance to the contrary, it would seem reasonable to report on a claim at least two primary chronic care diagnosis codes for which a CCM is being provided.

A practitioner can bill for CCM only after written consent has been obtained from the patient. Eligible beneficiaries must be informed about the nature of CCM and how the services are accessed, and they must be notified that their health information will be electronically shared with other practitioners involved in their care.

CMS requires continuity or patient access to care with a designated practitioner or member of the care team. Specifically, the practitioner furnishing CCM must provide the patient with the following:

  • A means to access a member of the care team at any time to address acute/urgent needs in a timely manner
  • The ability to obtain successive routine appointments with a designated practitioner or member of the care team
  • Enhanced opportunities—also available to any relevant caregiver—to communicate with the practitioner through telephone, secure messaging, internet, or other asynchronous consultation methods

It is strongly recommended that practices develop protocols and electronic health record (EHR) templates to capture the required CCM elements, especially given the non-face-to-face nature of the service. It may be necessary for practices to discuss options on how best to document time in the EHR with their EHR vendor. As stated previously, documentation must contain patient consent. The practitioner also must provide a detailed accounting and description of the non-face-to-face clinical staff time per calendar month and the name/credentials of the clinical staff furnishing the services. CMS identifies the following actions as counting toward the 20-minute requirement:

  • Performing medication reconciliation and overseeing the patient’s self-management of medications
  • Ensuring receipt of all recommended preventive services
  • Identifying and arranging for needed community resources
  • Monitoring the patient’s condition
  • Providing education and addressing questions from the patient, family, guardian and/or caregiver

Practitioners who are on call after hours must have access to the electronic care plan for documentation purposes (other than facsimile). Services can be provided “incident-to” the designated practitioner—that is, provided by a non-physician practitioner—if the CCM services are provided by licensed clinical staff under general supervision. The normal “incident-to” documentation requirements apply.

CMS expects CCM to be provided most frequently by primary care physicians, although specialists meeting the requirements also may bill for the services. Certain non-physician practitioners—such as nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse midwives—are eligible to furnish and bill Medicare for CCM, but only to the extent permitted under their state’s scope of practice.

A physician may arrange to furnish CCM services “incident-to” using a case management entity outside the billing practice; however, doing so does not negate the requirement for the billing practitioner to initiate the CCM service during a comprehensive evaluation and management visit, annual wellness visit, or initial preventive physical exam. This face-to-face visit is not part of the CCM service but is required before CCM services can be provided directly or under other arrangements. It can be separately billed to CMS. The billing practitioner must discuss CCM with the patient at this visit, which also presents an opportunity to obtain the required informed patient consent (although that consent can be obtained separately). The face-to-face visit included in TCM services (CPT 99495 and 99496) qualifies as a comprehensive visit for CCM initiation.

  • Transitional care management (CPT 99495-99496)
  • Home health and hospice care supervision (G0181-G0182)
  • End-stage renal disease services (90951-90970)

CMS has advised that the service period for CPT 99490 is one calendar month, and the agency expects the billing practitioner to continue furnishing services during a given month as applicable after the 20-minute billing threshold is met. Practitioners may bill the CCM service either at the conclusion of the service period or after completion of at least 20 minutes of qualifying services for the service period.

As shown in the exhibit below, the annual revenue potential in providing CCM services to Medicare beneficiaries can exceed $240,000 in new incremental revenue per physician (or other qualified practitioner). This analysis assumes a primary care physician with an average size patient panel, an average percentage of Medicare beneficiaries in that panel, and the average number of Medicare beneficiaries with two or more chronic diseases. In addition to the revenue potential, CCM offers providers a bridge over the chasm between fee-for-service and value-based payment. By developing and implementing a CCM program, a provider can grow skill sets and internal processes critical to population health management, all the while receiving fee-for service payment to support those activities.

Potential Chronic Care Management Gross Annual Revenue

How to Implement a CCM Program

Implementation of a CCM program involves five broad steps:

  • Identifying the patients
  • Designing the CCM process and schedule
  • Informing patients
  • Creating and documenting comprehensive care plans
  • Documenting time spent on CCM

Identify the patients. A healthcare organization can use its EHR to search for patients with two or more chronic conditions that are expected to last at least 12 months or until death. Each physician should then review reports of each patient and identify which are a good fit for CCM. Patients identified as candidates for CCM should then be categorized into one of three categories: significant risk of death, acute exacerbation/decompensation, and functional decline.

Design a CCM process and schedule. The organization should set up appointment codes for new visits and nurse assessment calls as needed. Staff should be assigned to assist with enrollment, consents, scheduling, and other related CCM activities. It may be a good idea to dedicate a phone line to be answered by designated CCM staff and forwarded to the on-call clinician after hours.

Inform patients. Patients should be educated on how the program works and given the option to decline, transfer, or terminate participation at any time. They also should be given information on how to terminate or transfer and, if they choose to participate, asked to provide their written consent and authorization of electronic communication of medical information with other clinicians (as allowed by state and local rules and regulations). The participation agreement should be reviewed with the patient, and their understanding of the agreement verified. Patients also should be provided with information about their obligations for payment of coinsurance and deductibles. Each of these steps should be recorded in the EHR, along with the name of the clinician.

Create and document comprehensive care plans. Each plan should include:

  • A systematic assessment of the patient’s medical, functional, and psychosocial needs
  • System-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management of medications

Document time spent on CCM. This step involves setting up a system that can keep track of time spent on non-face-to-face services provided, including:

  • Phone calls and emails with patients
  • Care coordination (by phone or electronic communication) with other clinicians, facilities, community resources, and caregivers
  • Prescription management/medication reconciliation

Transitional Care Management

TCM includes services delivered to patients whose medical and/or psychosocial problems require moderate or high-complexity medical decision making during transitions in care from an inpatient hospital setting (e.g., acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility (SNF)/nursing facility to the patient’s community setting (home, domicile, nursing home, or assisted living). Effective Jan. 1, 2013, under the Physician Fee Schedule, Medicare has paid for two CPT codes (99495 and 99496) that are used to report physician or qualifying non-physician practitioner care management services for a patient following a discharge from a hospital, SNF, or community mental health center, outpatient observation, or partial hospitalization. e

Two new codes will be used to pay for many of the non-face-to-face services that up until now were generally provided but not covered. Codes 99495 and 99496 both cover communication (by phone or email, or in person) with the patient or caregiver within two business days of discharge. Code 99495 involves medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge. Code 99496 involves medical decision making of high complexity and a face-to-face visit within seven days of discharge.

The requirements for TCM services include the following:

  • The services are required during the patient’s transition to the community setting following particular kinds of discharges.
  • The healthcare professional accepts care of the patient post-discharge from the facility setting without a gap.
  • The healthcare professional takes responsibility for the patient’s care.
  • The patient has medical and/or psychosocial problems that require moderate or high complexity medical decision making.

The 30-day TCM period begins on the date the patient is discharged from the inpatient hospital setting and continues for the next 29 days.

TCM services are furnished following the patient’s discharge from an inpatient acute care hospital, inpatient psychiatric hospital, long-term care hospital, SNF, inpatient rehabilitation facility, hospital outpatient observation or partial hospitalization, or partial hospitalization at a community mental health center.

Following discharge from one of the above settings, the patient must be returned to his or her community setting, such as his or her home, a nursing home, or an assisted living facility.

Physicians or non-physician practitioners may furnish the following non-face-to-face services:

  • Obtaining and reviewing discharge information such as discharge summary or continuity of care documents
  • Reviewing need for or follow-up on pending diagnostic tests and treatments
  • Interacting with other healthcare professionals who will assume or reassume care of the patient’s system-specific problems
  • Providing education to patients, families, guardians, and/or caregivers
  • Establishing or reestablishing referrals and arranging for needed community resources
  • Assisting in scheduling required follow-up with community providers and services

Services furnished by licensed clinical staff under the direction of a physician or non-physician practitioners include:

  • Communicating with agencies and community services used by the patient
  • Providing education to patients, families, guardians, and/or caretakers to support self-management, independent living, and activities of daily living
  • Assessing and supporting treatment regimen adherence and medication management
  • Identifying available community and health resources
  • Assisting patients and/or their families in accessing needed care and services

First Steps

To successfully implement a TCM or CCM program, hospital-owned physician enterprises should conduct a gap analysis of their current capabilities and resources compared with the total resources required to fulfill the CCM and TCM requirements. This analysis would include reviews of Medicare patients with chronic conditions and of plans to use ancillary nursing staff as appropriate under the “incident-to” provisions or to retain an outside call management service for after-hours calls from CCM enrolled patients. Careful attention should be paid to all aspects of TCM and CCM programs to ensure the practice is prepared. 

Cathy Zito is CEO, Lighthouse Healthcare Advisors LLC, Cockeysville, Md.

Joette P. Derricks is CEO, Derricks Consulting, Hunt Valley, Md.


a. CMS, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Prepayment Complex Medical Review and Other Revisions to Part B for CY 2013; Final Rule” Federal Register, Nov. 16, 2012, pp 88-103.

b. CMS, “Chronic Care Management Services,” December 2016.

c. James, C.V., “Mapping Medicare Disparities,” CMS blog, April 11, 2016.

d. Centers for Disease Control and Prevention, “Chronic Diseases: The Leading Causes of Death and Disability in the United States, Page last updated, Feb. 23, 2016.”

e. This policy is discussed in the CY13, CY15, and CY 2016 PFS regulations.

f. CMS encourages practitioners to follow CPT guidance in reporting TCM services (see the CPT definition of the term clinical staff). Medicare requires that applicable state law, scope of practice, and incident-to rules be met before a practitioner is permitted to bill the Medicare Physician Fee Schedule for TCM services. The practitioner must meet the “incident-to” requirements described in Chapter 15 Section 60 of the Benefit Policy Manual 100-02.


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