Chronic Care
Management: Clinical
Case
Linda V. DeCherrie, MD
Director, Mount Sinai Visiting Doctors Program
Associate Professor – Department of Geriatrics and
Palliative Medicine
Faculty Disclosures
• DeCherrie – no relevant disclosures
Objectives
• Use the information presented to improve their
care planning practices.
Clinical Case
• 76 yo woman with :
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Osteoarthritis
H/o CVA 3 years ago
Vitamin D deficiency
Endometrial cancer s/p resection
Depression
MALT lymphoma
CHF
Mild cognitive impairment
• Homebound because of ambulation issues and was referred to
program 1 year ago by resident
Clinical Case
• Multiple clinical issues:
• Falls
• Needing more support in the home
• Identifying a health care proxy and goals of care
• Medication management
• Transportation to her GI for follow up of MALT lymphoma
• Electric wheelchair broken
Care Team at Mount Sinai
Visiting Doctors
• Physicians
• Nurse practitioners
• Nurses
• Social work
• Administrative assistants
Chronic Care Management
(CCM)
• New CPT code in 2015 – 99490
• Non face-to-face Care management
• Approximately $43 with standard co-insurance
applies; $90 for hospital-based practices
CCM Requirement – Overview
• Applies to Medicare Fee-for-Service Program
• Beneficiaries with 2 or more chronic conditions
• 20 minutes of qualifying time
• Only one practitioner can bill per month
• Transitional Care Management, Care Plan
Oversight and certain ESRD services
payments cannot be billed the same month
CCM Beneficiary
• Medicare Fee-For-Service
• Consent to the services
• 2 or more chronic conditions expected to last
at least 12 months or till death
• Conditions place beneficiary at risk of death,
acute exacerbation/decompensation or
functional decline
Back to Clinical Case
• Program ready to start billing CCM March 2015
(consent form through vetting
process/translated and EMR and billing
software ready)
• Consented patient in April 2015
Social Worker
• Met with patient multiple times in person (not CCM)
and telephonically:
• Work on transportation issues
• Arrange patient to change managed medicaid to a plan where she
could get her wheel chair fixed
• Identify family members
• Worked with NP for patient to identify GOC and HCP
• Applied for more hours of an aide at home with patient
Nurse Practitioner
• Met with patient multiple times in person (not CCM)
and telephonically:
• Multiple calls with home health (RN and PT) for falls and medication
issues
• Helped identify GOC and HCP with SW
• Proactive calls to patient to see progress with treatment plans
Nurse
• Office based telephone triage:
• Took many urgent calls for falls and other
issues from patient
Billing
• May – December – billed CCM 4/7 months
Challenges with CCM Billing
• Practice/provider/team education
• Obtaining consent from patients
• Co-pay related to Non face-to-face encounter
• Recording/Tracking time for all encounters
Discussion
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