State of CMS Chronic Care Management Program as Clinics Prepare to Transition to Endemic Phase of COVID-19

January 3, 2022

Last year a team of researchers from the University of Washington in Seattle (UW Seattle) sought out to study the still somewhat not-well understood Chronic Care Management (CCM) program funded by the Centers for Medicare and Medicaid Services (CMS).  Initiated just over five years ago, little is still known about the uptake over time report by the academic scholars led by corresponding author Ashok Reddy with both the University of Washington Department of Medicine and the U.S. Veterans Administration.   The author’s findings, now well over a year old, indicate a growing program with many kinks to work out for rapid scalability.  For example, 5% of all chronic care management claims in 2020 were still denied by CMS, underscoring an urgent need for better understanding how to facilitate improvements as well as barriers to use. 

The CMS CCM program covers a large percentage of the U.S. Medicare population.  With approximately 62.6 million people on Medicare, based off of CMS Multiple Chronic Conditions table, CrossTx estimates that approximately 67% or 41.9 million beneficiaries are eligible for the care coordination program given they have at least two chronic conditions. This means that eligible clinics that offer care coordination for these patients can be reimbursed for their efforts.   This CMS program can introduce significant new revenue streams to the eligible, participating clinic or health center. Moreover, nearly two dozen state Medicaid offices will match the Medicare payment at least partially!

There are, in fact, many beneficiaries eligible for this program across the United States that haven’t received any chronic care management reimbursement to date while according to the study last year still only a minority of clinicians participate in the program.

What’s the value of the CCM program?

With nearly 42 million Medicare beneficiaries eligible for the CCM program—also known as a transitional value program—this represents the eligible Medicare beneficiaries with chronic conditions.   U.S. CMS data reveals that Medicare patients with chronic conditions incur over 90% of all Medicare spending while facing growing care fragmentation, reports the authors of the Seattlebased study.

In 2015, Medicare introduced the CCM program including billing codes used to track the time and effort associated with the care coordination program.  While reimbursement commenced six (6) years ago, the program has taken time to become reputable in the mainstream clinical ecosystem.

Established to support the over 180,000 primary care physicians across America caring for Medicare patients, the program offers a longitudinal, “non-visit-based care” model that includes ongoing disease management and coordination across clinicians and community organizations.

How does it Work?

Clinicians, a nurse, or other care coordinator employed at an eligible clinic or health center offer care coordination services targeting patients with two or more chronic conditions every month. These services start with a comprehensive care plan, tracked, and monitored, and often revised based on the unfolding patient situation.

Chronic care management is made possible by CMS billing codes, which started first with current procedural terminology (CPT) code 99490 and G0511 for Rural Health Clinics.  Additional codes came online including CPT 99487 and 99489 addressing complex care management.  Then G0506 was introduced by 2017 when the physicians themselves direct the chronic care management.

What’s the Update by 2020

The 2020 study led by the UW Seattle team indicated a relatively slow uptake. Out of 180,000 eligible clinicians, only 16,459 clinicians delivered such services representing about 9% of the total number of eligible clinicians.  The study team reported that from 2015 to 2016, 684,584 Medicare patients over the first couple years of the program benefited from ongoing care coordination. Of course, this total represented a fraction—just over 1% of the total number of Medicare beneficiaries.

While Medicare continues to emphasize and promote the program, the number of total patients in the program undoubtedly has grown—aided by CMS acknowledging the changing needs of complex care.  The federal government thus allowed both physician and non-physician team member participation in the program.  By 2020 the Medicare physician fee schedule boosted chronic care management payments and expanded other care coordination programs.  The UW Seattle authors emphasize however that “Despite increasing policy emphasis, however, little is known about longer-term trends in chronic care management use, particularly regarding services provided to complex patients.”

The Study Methods

UW Seattle research members tapped into, sliced and diced CMS Medicare data from 2015 to 2018 reviewing 100% of CCM claims submitted to Medicare by clinical physicians across the country.  The team both calculated and compared utilization and payment by physician specialty. They employed X2 tests to compare variables across specialist categories.  Using two-tailed statistical tests at α = 0.05  the team employed the statistical program SAS for the results.

The Results

Published in the peer-reviewed Annals of Medicine, the team shared that for the study period of 2015 to 2018 the great majority of payments derived from the original CCM CPT 99490 at 93% of all CCM services. Meanwhile only 7.9% in 2017 and 10.6% by 2018 of all payments associated with complex CCM care management services (CPT 99487, CPT 99489 and G0506)

The study team reports that overwhelmingly primary care physicians (78%) deliver the CCM services versus specialists (8%) and others at 14% with a P<.0001.

What revenue was generated between 2015 to 2018?  According to this important study, primary care physicians, again the primary drivers of CCM in these first three years, increased services from 810,289 to 3.4 million representing an increase in revenue from $33.7 million in 2015 to $151.9 million in 2018, a sizable increase.

Specialists increased the number of CCM services from 60,511 in 2015 to 448,821 in 2018.  Again, the authors found CMS identified 4.8% of call submitted CMS services—the denial figures equaled 5.7% in 2015 and 5.4% in 2018.

Service Counts & Payments CCM program (source CMS data)

CrossTx does note that the UW Seattle-led study does include some limitations including the lack of granular practice as well as patient level data.  However, the authors report that “to our knowledge, this study is the first to describe longer-term trends in CCM use, with an emphasis on complex care management and denied services among primary care clinicians as key providers of coordination services.”

2020+ Challenges & Opportunities

CrossTx is a leading provider of CCM services via its cloud-based care coordination and closed-loop referral management system for CCM. The easy to access and use system includes purpose-driven workflows, time tracking, reporting and audit tracking to ensure compliance adherence with CMS CCM billing requirements.

With nearly 1000 hospitals and various clinics using the CrossTx CCM platform for not only Chronic Care Management but also Behavioral Health Integration and Complex Chronic Care Management, CrossTx’s leadership is well positioned to observe growing opportunities and challenges.

The pandemic led to shortages in health care staff across America which impacted the advancement of programs across the country. CrossTx offers staff augmentation services to ensure that eligible clinics can fully capitalize on this CMS program.  Moreover, many hospitals and health systems increasingly require that all CCM activity occur in the electronic health record.  Problematically these often-rigid platforms aren’t designed with the flexibility and specificity necessary to meet CCM reporting and time tracking requirements. However, CrossTx has developed a sophisticated interoperability and can seamlessly interface with all major electronic health record systems such as Cerner or Epic.

As the COVID-19 pandemic moves to an endemic phase, health centers, hospitals, and clinics across the United States will seek ways to both improve care for Medicare patients as well as drive more revenue. CrossTx offers an immediate way to leverage existing electronic health record technology while immediately benefiting from a sophisticated, purpose-built CCM service.  CrossTx can boost revenues into the millions of dollars.

Daniel O’Connor
Chief Business Officer


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