By now you’ve likely heard that qualifying physicians can receive approximately $42/patient/month from CMS for non-face-to-face care management of patients with two or more chronic conditions. And, in many cases, with the right tracking and reporting, you may be able to capture this revenue for work your team is already doing. In just 30 minutes, you will understand the chronic care management program requirements and see how easy it is to capture and report qualifying activities.

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Chronic Care Management (CCM):
Understand how to capture
Incremental revenue
November 10, 2015
Presented by:

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• Introduction
• A problem in healthcare
• The research
• The opportunity for CCM
• The requirements For CCM
• A solution you can leverage
• Next steps in working together
Welcome
Presenter: Todd Melioris,
Executive Vice President

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• Highlight the current issues surrounding care for patients with
chronic diseases
• Understand CMS requirements for the new Chronic Care
Management reimbursement code
• Learn how you can improve care for patients and increase
revenue through CCM
• Discover tools that can help you leverage the manpower and
practices you already have in place
• Information from public domain:
– Center for Medicare and Medicaid Services (cms.gov)
– Center for Disease Control (cdc.gov)
Objectives

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• 130+ million Americans have
chronic diseases
• 7 of the top 10 causes of death in
US in 2010 were chronic illnesses
• 85% of healthcare spending goes
to the treatment of chronic illnesses
• 2/3 of Medicare dollars are spent
on patients with 5+ chronic
conditions
The Problem

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• 76+ % of Medicare
beneficiaries have 2 or more
chronic diseases, resulting in:
 80+ % of hospital admissions
 90+ % of prescriptions filled
 75+ % of physician visits
• Providers historically have not
been reimbursed for non-face-
to-face care coordination
services
• What is the outcome for this
environment?
The Research

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• Chronic disease patients are often left to themselves to coordinate
care between visits
• Gaps in communication cause:
– Fragmented health data
– Duplicated tests
– Increased healthcare expenses
– Increased likelihood of poor health outcomes
Effective Chronic Care Management:
Reduces the costs of care for chronic disease patients
Improves their overall health
Increases quality of life
The Research - continued

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The Opportunity
• Importance of Chronic Care Management (CCM)
• Impact that it has on healthcare expenses
• Improved patient outcomes
Centers for Medicare & Medicaid Services (CMS) recognizes:
• Medicare beneficiaries with 2+ chronic conditions
• 20+ minutes of non-face-to-face chronic care coordination
• Services can be fulfilled by the provider or performed by
subcontractor
• Pays approximately $42 per patient per month to providers
New Chronic Care Management CPT Code 99490
Medicare has not recognized CCM as a rural health clinic (RHC) or federally qualified health center (FQHC) ser

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• Only 1 provider can receive CCM reimbursement for a patient
• Average Family Practitioner or Internal Medicine Practitioner has
2000 patients and roughly 500 qualify for CCM
• A large percentage of qualified patients have supplemental
insurance – resulting in no cost to patient
• 450 patients per provider at $42 per month
The Opportunity – continued

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The Math
Providers Dollars
1 $226,800
10 $2,268,000
100 $22,680,000
500 $113,400,000
1000 $226,800,000
Providers are likely already performing many of the required services
– and are not getting paid for it.

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Providers:
• From Reaction to
Improvement and
Prevention
• Improved patient
compliance
• Medication management /
monitoring
• Care Plan monitoring
• Increase Revenue – 99490
+ Additional office visits
Patients:
• Decrease ER Visits and
Hospital Admittance
• Frequent interactions and
support
• Reinforcement of desired
behaviors
• Reduce long-term
healthcare costs
• Improved quality of life
The Benefits

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• Creation of Patient Centered Care Plan
• 24/7 Patient access to clinical staff involved in Care
Team
• Certified EHR that includes Care Plan accessible
24/7 to Care Team Providers
• Continuity of care with designated Provider
• Perform Medication Management / Reconciliation –
Adherence
• Ongoing care management for all chronic conditions
• A comprehensive care plan that includes all current
records from all the patient’s providers
• Management of care transitions between and among
all providers
The Requirements

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• Certified EHR
– Any provider billing for CCM is required to use an EHR that
satisfies the 2011 or 2014 criteria of the EHR Incentive Program.
• Maintain a regularly updated, electronic Care Plan
– Should include all of the patient’s healthcare providers, family &
caregivers, all health conditions - not just those considered chronic
– Be aligned with the patient’s choices and values
– CMS recommendations for the Care Plan:
 Comprehensive problem list, including expected outcome, prognosis
and measurable treatment goals
 Symptom management and planned interventions
 Outline Accessible community and social services available
 Plan for care coordination among all providers
 Medication management, including current medication list and
allergies, reconciliation, and oversight of patient self-management
The Care Plan

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• CMS has left the ruling open to discernment by provider.
• The guideline require:
– 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,
or acute decomposition
• CMS maintains a Chronic Condition Warehouse (CCW) with 27
chronic conditions listed to provide researchers with beneficiary,
claims, and assessment data, however, it is not an exclusive list.
https://www.ccwdata.org/web/guest/medicare-charts/medicare-chronic-condition-charts
Eligible Patients and Chronic Conditions

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• Alzheimer’s Disease
• Anemia
• Arthritis
• Cancer
• Depression
• Diabetes
• Glaucoma
• Heart Disease
• Hypertension
• Obesity
• Osteoporosis
• Etc…
Examples of Chronic Diseases that Qualify for CCM

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What you need to do:
• Collect medical records from all patient providers to build a
comprehensive Care Plan and health summary that includes the
CMS-required elements.
• CMA, Nurse, PA or Physician at practice spend a minimum of 20
minutes per patient, per month assisting with care coordination
tasks including scheduling medical visits, reconciling medication lists,
updating care plans.
• Have a clinical care team member available 24/7 by phone, online,
and through mobile messaging to help patients with acute chronic
care issues and care coordination tasks.
• Facilitate care transitions, document the information, and keep all
members of the care team up-to-date.
• Record medical visits and provide access to the documentation to
other care team providers.

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Explain the CCM
program and benefits
to qualified patients
during Annual
Wellness Exam.
Checkout:
• Patient signs the
Consent Form
• Care team verifies
contact information
Build Care Plan and
share with patient
Call patient monthly
• Internal and external
communication must equal
20+ minutes
Continue with your
acute care
management as
usual
Bill monthly for CCM
patients that meet the
20+ min care
coordination
Your workflow for CCM

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Diagnotes is a HIPAA-compliant communication
platform that drives effective care team collaboration
Patients, providers and staff
can send secure text
messages with patient data
to individuals or groups.
Alerts and messages
can be routed to
providers based on
specialty, care location
and availability.
All activity can be documented,
reviewed and archived for care
continuity and billing.
Phone calls and voice
messages can be
securely handled by call
center agents or by an
auto-attendant.
Key patient data from medical
records can be automatically
retrieved and delivered to message
recipients.

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Diagnotes is easy to learn and effective to use
Seamlessly collaborate with care teams and automatically track and retain
all communication to protect your program during audits.

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Diagnotes makes CCM reimbursement possible

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Diagnotes satisfies the entire enterprise
iOS, Android, and web-based
BYOD-enabled: no cached data on mobile devices
SaaS-based, cloud-hosted
Makes it affordable
EHR-agnostic
Links to any EHR, HIE or other data source
HIPAA-compliant
No worries about sending or receiving PHI
Administration-friendly
Includes call scheduling, audit trail and analytics

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• Diagnotes improves communication and
coordination among patients, providers and staff
Proven
Solution
• Increase revenue
• Decrease cost
• Enhance patient and provider satisfaction
Clear
compelling
value
• Award-winning, cost-effective solution
• Top notch service and support
• Experienced team
Positioned for
your success
Why choose Diagnotes?

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Our customers are solving problems

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• Call (317) 395-7080 for a:
– CCM Evaluation for your practice
– Demonstration
• Visit our website at www.diagnotes.com
Next Step
THANK YOU