Susan Harkema

Chronic Care Management supports patients in managing their chronic conditions, preventing future illness, slowing disease progression, and avoiding exacerbation. A CCM program typically includes a variety of services proven to support chronic disease management, including: Patient-centric care planning Personalized goal setting Guided clinical or health risk assessments Monthly touchpoints via phone or telehealth Ongoing medical supervision and intervention Patient education about medical conditions, treatments, self-management

Medicare’s Chronic Care Management (CCM) program supports patients in managing multiple chronic conditions, slowing disease progression, preventing costly care, and enhancing quality of life. Nurses play a crucial role in this program, particularly for high-risk, vulnerable populations. The Institute of Medicine affirms the expanding role of nursing in CCM, stating in a report, “Nurses are being called upon to fill primary care roles and to help patients manage chronic illnesses, thereby preventing acute care episodes and disease progression.”

An overarching shift has taken place over the past 100 years. It’s picked up speed in the last 20. Medicine has transitioned from a focus on infectious and non-communicable diseases to the prevalence of chronic illness. The National Council on Aging (NCOA) reports that 78.7% of adults over age 60 have two or more chronic conditions, while 42% of adults overall have at least two, and 12% live with five or more chronic conditions. For those over 50, multimorbidity is projected to rise by 91% by 2050.

Many Medicare billing guides focus on reimbursement requirements but often lack clear steps on how to successfully and accurately bill Medicare for RPM services. Billing processes, steps, and tools can support seamless and successful reimbursement or cause frustration, denied claims, and double work. As a Medicare program to monitor patient vitals at home, Remote Patient Monitoring (RPM) collects data that providers can use to manage chronic and acute conditions, foster patient engagement, and prevent disease progression or hospitalizations.

In 2019, the Center for Medicare and Medicaid Services (CMS) launched its Remote Patient Monitoring (RPM) program, to reimburse providers for using digital technology to monitor patients between visits. The program covers collecting and transmitting patient clinical data. It also supports a clinician’s time to review the data and intervene if it indicates a harmful clinical change. Medicare, the first to cover RPM more than twenty years ago, continues to expand the program, supporting more billing opportunities for providers.

Medicare’s Remote Patient Monitoring (RPM) program reimburses providers for: Using digital devices to collect and transmit patient clinical data Clinician’s time to review the data to make changes to the patient’s care plan Intervening if clinical data indicates an exacerbation that could be detrimental to the patient The Centers for Medicare & Medicaid Services (CMS) developed this program to help providers monitor patients’ chronic and acute conditions in real time, improve patient engagement, and develop comprehensive care plans that enhance health outcomes.

Chronic Obstructive Pulmonary Disease (COPD) is the fourth leading cause of death in the US, killing more than 150,000 people each year. COPD is a progressive and incurable lung disease experienced in two primary forms: chronic bronchitis and emphysema. More than 16 million Americans are diagnosed with COPD, and another 14 million are estimated as undiagnosed. Providers utilizing Medicare’s Chronic Care Management (CCM) program concurrently with Remote Patient Monitoring (RPM) can help slow the disease’s progression, prevent exacerbations, and provide more timely interventions. This can lead to reduced mortality and improved quality of life for patients, as well as enhanced reimbursement for providing more active and personalized disease management.

Over the past 20 years, the number of chronic diseases has increased steadily. Today, 42% of adults have two or more chronic conditions, and 12% have at least five. The number of adults over 50 with at least one chronic disease is expected to increase from 71.5 million in 2020 to 142.6 million by 2050. Just seven chronic diseases cause two-thirds of mortality in the US and consume 86% of annual healthcare spending. Given these trends and research, the Centers for Medicare & Medicaid Services (CMS) launched the Chronic Care Management program in January 2015. This program aimed to improve Medicare beneficiaries’ access to chronic care management in primary care and provide a value-based care model to reimburse physicians for more robust care coordination.

One of the powerful aspects of Medicare care management programs is that some are designed to work together. A primary example is offering Chronic Care Management (CCM) alongside Remote Patient Monitoring (RPM). CCM and RPM can be billed together when each program independently meets the requirements set by the Centers for Medicare & Medicaid Services (CMS). But why go to the effort and expense to launch two programs, and how should you practically bill both concurrently? Lastly, what does this look like for Rural Health Clinics and Federally Qualified Health Centers?

Over a decade, the Centers for Medicare & Medicaid Services (CMS) tested various value-based innovation models focused on improving primary care. Models like CPC, CPC+, and Primary Care First demonstrated that “comprehensive primary care can lead to reductions in emergency department and hospital visits while better meeting patient needs.” In 2024, CMS introduced new reimbursement opportunities for primary care practices through the 2025 Medicare Physician Fee Schedule Proposed Rule. Referred to as enhanced care management, Advanced Primary Care Management (APCM) is meant to support primary care physicians in their transition to value-based care. Ultimately, their goal is to promote longitudinal relationships between clinicians and patients while reimbursing for risk-stratified care management services.

More than 60% of older Americans receive help from unpaid caregivers; typically, these include family, friends, or neighbors. Engaging family as part of the patient’s overall care team has been shown to improve chronic disease management, including: Medication adherence Self-care Clinical outcomes Continuity of care Health literacy Readmission rates Emotional support and motivation We’ll explore the benefits of engaging a patient’s inner circle in managing chronic illnesses through care management programs. We'll also highlight when and how to involve informal caregivers in patient care and how ThoroughCare facilitates deeper family engagement.

The Centers for Medicare & Medicaid Services (CMS) created the Shared Savings Program (SSP) to encourage physician groups, hospitals, and other healthcare providers to support more coordinated, high-quality, and cost-effective care. SSPs focus on chronic conditions: Nearly 80% of Medicare spending is delivered to beneficiaries with five or more chronic conditions. Also, nearly 99% of expenditures are for beneficiaries with at least one, so these alternative payment models (APMs) emphasize chronic disease management. SSPs focus on care coordination: According to research by the RAND Corporation and others, effective care coordination is vital, considering that a single medical condition can require up to 50 interactions between the patient and their care team in three months. SSP participants work to streamline care, reduce duplicate or overutilization, and drive efficiency. SSPs focus on lowering the cost of care: Research shows that the average annual Medicare spending for beneficiaries with one or two chronic conditions is more than double that for those with no chronic diseases. Plus, Medicare expenses for beneficiaries with five or more chronic diseases are nearly nine times the average for a person with no diagnosed chronic conditions. SSP participants seek to decrease Medicare and beneficiary costs.

The Centers for Medicare & Medicaid Services (CMS) launched Z codes in 2015. They are a set of ICD-10-CM codes that identify non-medical factors that may affect a patient's health status or ability to fully benefit from treatment. They were released for billing and research purposes, yet no reimbursement is associated with their use. While the intention for Z codes to capture health-related risk factors like social determinants of health (SDOH) is a valid step toward improved health outcomes and health equity, research has shown increasing but scant use. Only 0.11% of all fee-for-service Medicare claims indicated a Z code, representing more than 1.2 million claims.

The US Center for Disease Control and Prevention defines health literacy as "the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others." According to the US Department of Health and Human Services, only 12% of US adults have proficient health literacy. This shows that, across all levels of education, 88% of Americans have less-than-proficient health literacy levels.

The Centers for Medicare & Medicaid Services (CMS) created the Shared Savings Program (SSP) to encourage physician groups, hospitals, and other healthcare providers to support more coordinated, high-quality, and cost-effective care. Alternative payment models enable combinations of value-based and fee-for-service payments. With an emphasis on Traditional Medicare beneficiaries, the three APM initiatives are covered here.

A patient’s chronic illness journey is cyclical and complex. It's not a linear path but a continuous loop of pre-service, service, and post-service interactions with the healthcare system. Without adequate self-management, health literacy, and personal discipline, a patient’s health can deteriorate, and their condition worsens significantly. For high- or rising-risk patients diagnosed with one or more chronic diseases, care management offers six primary benefits.

Health plans have extensive experience with care management, technology, and pilots. However, what’s new is leveraging all three to better collaborate with providers to enhance Chronic Condition Management, engage and activate members more deeply, and facilitate overall cost savings. Research shows that all health plans offer care management programs regardless of size, location, and ownership. And, while these payors’ “internal evaluations suggest that interventions improve care and reduce cost, plans continue to report difficulties in engaging members and providers.”

Approximately 93% of primary care physicians wish they had support to better engage patients with multiple chronic conditions, according to a Quest survey. However, 85% feel they lack enough time to give patients the level of care they need. Only 9% believe their complex patients receive adequate care for their conditions. Despite these views, 77% of these same doctors have not implemented a Chronic Care Management (CCM) program to improve outcomes.

In the US, diabetes affects more than 38 million adults, making up 11.6% of the population, costing more than $306 billion in direct medical costs. Adults aged 65 and older represent 29.2% of people diagnosed and undiagnosed with diabetes, increasing by 1.2 million each year. After adjusting for age and gender, people with diagnosed diabetes experience 2.6 times higher healthcare expenditures.

Gastroenterology is a complicated specialty that helps patients with multifaceted clinical and quality-of-life issues. Yet, these providers face increased challenges, such as falling reimbursements, increasing patient demand, and physician shortages. In light of these trials, gastroenterologists need strategies to streamline effective gastrointestinal disease treatment and provide scalable and personalized care that enhances revenue.