Leveraging CMS reimbursements for post-acute and chronic patients

Stephanie Jackson | Medicare, Care Coordination, Care Industry News, | May 08, 2017

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has been reimbursing doctors and health care organizations for providing chronic care management. Unfortunately, many organizations are not receiving this reimbursement and may be missing out on federal funding for some of the sickest Medicare beneficiaries. With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians, and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services. 

What are the CMS reimbursements?

As reported by ModernHealthCare, CMS made payments for chronic-care claims for just 513,000 Medicare beneficiaries of the approximately 35 million individuals eligible for this program. (To be eligible, individuals must have two or more chronic conditions.) Some of this gap stems from physicians' overall lack of awareness of the billing code for care management. However, by speaking with physicians, coordinating chronic-care services and using the right care-management billing codes, CMS will reimburse physicians and health care organizations for their time. 

The source noted that approximately 70 percent of Medicare beneficiaries have two or more chronic conditions. Examples of the covered conditions include, but are not limited to:

  • Alzheimer's disease and related dementia.
  • Arthritis (osteoarthritis and rheumatoid).
  • Asthma.
  • Diabetes.
  • Hypertension.
  • Depression.
  • Cancer.

Hospitals that partner with acute care nurses, discharge planners and care coordinators can take advantage of the average $42 per patient per month reimbursement for chronic-care service coordination and specialist consultations.

As noted in ModernHealthCare, another reason some health care providers are not taking advantage of this opportunity is due to the necessary written patient permission for the reimbursements. However, the 2017 add-on now eliminates the need for written consent and allows a verbal okay from patients.

According to CMS, the payable CCM service codes include:

  • CPT code 99490: covers 20 minutes of clinical staff time once a month for patients with two or more chronic conditions at significant risk of death or functional decline. The chronic care management services are required to have established, implemented, revised or monitored a comprehensive care plan.
  • CPT code 99487: covers 60 minutes per month of clinical staff time for complex chronic care involving moderate or high complexity medical decision making.
  • CPT code 99489: covers additional 30-minute block for qualified clinical staff time, once per month.
  • HCPCS code G0506: an add-on, covers qualified clinical staff time for the initiating visit with a patient to develop a comprehensive assessment and care plan.

Some of the services included under the CCM cover:

  • Continuity of care with designated care team members.
  • Comprehensive care management planning.
  • Transitional care management.
  • Coordination with home- and community-based clinical service providers.

Qualified clinical staff include:

  • Physicians.
  • Certified nurse midwives.
  • Clinical nurse specialists.
  • Nurse practitioners.
  • Physician assistants.

CMS also noted that CCM services are priced in both facility and non-facility settings, including skilled nursing, nursing, assisted living or other facility settings.

Reducing patient hospital readmittance

Patient readmittance in the first 30 days results in a CMS reimbursement penalty, so it's imperative that discharge nurses have top quality care providers for post-acute and chronic patients.

Unfortunately, research studies showed that 17.3 percent of Medicare fee-for-service patients aged 65 and over were readmitted within 30 days in 2012, according to the National Health Statistics Report. Readmissions occurred due to care coordinators poorly managing transitions during discharge, infections or complications caused by the hospital stay or the reappearance of the condition that led to the hospitalization in the first place.

Reducing readmissions falls on care coordinators in charge of locating care providers with the skills and qualifications that best suit the needs of the patient.

To accomplish this, care coordination companies, such as hospitals or health IT companies, are building discharge-planning software. However, these platforms need a robust database of talented and experienced care providers to ensure post-acute and chronic patients recover quickly and do not need readmittance.


Care coordinators need to reduce the hospital readmission rate of chronic patients.

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Follow-up calls between visits to primary care physicians

One way to help reduce the chances for chronic and acute patient readmission is to provide ongoing treatment and care following a hospital discharge. This enables an open dialogue and regular visits to ensure the patient is following the physician's recommendations. 

Individuals receiving ongoing treatments from their primary care physicians and suffering from two chronic conditions need extra care providers in between doctor visits. Aligning these care services along with the CMS reimbursement is important to capture lost revenue opportunities.

How Carelike can help

Sometimes the biggest obstacle to taking advantage of the CMS reimbursement is finding the best-suited care providers to deliver post-discharge and follow-up services. Matching a nurse without the right qualifications can lead to readmission, which penalizes the reimbursement. Often, as noted by the Center for Healthcare Quality & Payment Reform, the inability to receive good primary care support in the local community is a main contributor to preventable readmissions.

Care coordinators arranging for discharge planning or long-term follow-up services for chronic patients need easy access to a wide range of care providers. Further they need the ability to accurately tailor their searches to locate the most appropriate health care professional to align with unique care seeker needs. By identifying the best local care providers for managing post-discharge chronic care patients, hospitals can reduce their readmission rates and ensure they're receiving the full CMS reimbursement.

Carelike creates a custom portal for care coordinators, who can then use licensed data that focuses on either national or local/regional care providers. Hospitals that already have their own systems can rely on Carelike's API that simply plugs into existing systems for easy access to the extensive database.

Using Carelike's dashboard, care coordinators can easily track patient statuses, add noted, document care transitions and take advantage of the extensive database of providers who all manage chronic and post-acute conditions. This provides an additional layer of context during the transition phase that's crucial for communicating additional information about patients.

Companies in the process of building a software solution to meet the growing need of matching care providers with care seekers could benefit from using the Carelike database.

Carelike provides the technology and resources to help hospitals, health care organizations and care coordinators take advantage of CMS reimbursements for chronic care and post-acute care management. Click here to learn more about Carelike.