Earlier this year the Centers for Medicare and Medicaid Services (CMS) provided an opportunity for physicians and health systems to get a glimpse of the future of health care reimbursement, and essentially “test drive” it before it becomes a reality. 

They did this by creating a current procedural terminology (CPT) code for chronic care management (CCM) services that will provide physicians with additional reimbursement if they meet certain requirements. 

In CliftonLarsonAllen’s view, the concept of this CPT code is directly in line with the desired evolution of health care to manage the health of a population of people.

Reimbursing for care management

CMS has long recognized that care management is a critical component to primary care services that, when delivered effectively, will lead to improved health and reduced spending for Medicare beneficiaries. Until January 1, 2015, however, the reimbursement system did not effectively reimburse physicians for care management services that took place outside of a traditional face-to-face visit. 

Physicians and other practitioners are now eligible to be reimbursed for non-face-to-face care coordination activities by using CPT code 99490 when they meet specific eligibility criteria. The total reimbursement for these care coordination activities would amount to about $43 per eligible beneficiary per month. 

While this may not sound significant on the surface, it can add up. At the same time, the motivation for the reimbursement -- rewarding effective care management -- can lead to improved patient outcomes and experiences.

Qualifying for reimbursement

In order to qualify for the additional reimbursement, physicians and the Medicare beneficiary receiving the service must meet specific criteria. A high level overview of those requirements is as follows:

  1. At least 20 minutes of clinical staff time directed by a physician or other qualified health care professional must be spent on care management per calendar month.
  2. The beneficiary must have two or more chronic conditions that are expected to last at least 12 months or until the death of the patient.
  3. The chronic conditions put the patient at significant risk of death, acute exacerbation or decomposition, or functional decline.
  4. A comprehensive care plan must be established for the patient, and this plan must be implemented, monitored, and revised as necessary.
  5. The patient must have access to the physician or other qualified member of the health team 24 hours per day, 7 days per week.
  6. The patient must be informed that CCM services will be provided, and sign a consent form to authorize sharing of medical information with other providers.

CMS has provided an example of the types of chronic conditions that could potentially allow the use of CPT code 99490. They include:

  • Alzheimer’s disease and related dementia.
  • Arthritis.
  • Asthma.
  • Cancer.
  • Diabetes.
  • Depression.
  • Hypertension.
  • Chronic obstructive pulmonary disease.

Who is eligible to bill for services?

To support the implementation of care coordination activities, CMS provided exceptions to Medicare’s “incident to” rules that allows certain clinical staff to provide CCM services under the general supervision -- rather than direct supervision -- of the billing physician. 

According to CMS, physicians and the following practitioners are eligible to bill for CCM services:

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

Business case considerations

In any transformation it is important to understand not only the clinical requirements and benefits, but also the impact on the organization from a reimbursement and financial perspective.

To evaluate the business case for considering CCM services, we completed an analysis that assumes a patient panel size of 2,000 patients. Of that total patient population, we assumed 35% were Medicare beneficiaries, and that 33% of those Medicare beneficiaries would be eligible for CCM services due to multiple chronic conditions and meeting the CMS criteria. 

Based on these assumptions, about 231 patients would be eligible to receive CCM services, for which the practitioner delivering those services would receive reimbursement of just over $118,000 on an annual basis.

The team assembled to provide CCM services would have to spend a minimum of 20 minutes per month for each patient, or just under 80 hours per month on the 231 patients.

What should you do?

CCM services represent a real opportunity for those willing to embrace the health care transition taking place. While there are many details to understand and processes to implement, one thing is for sure -- CMS has created an opportunity for practitioners to be reimbursed for non-face-to-face care coordination services.

So what must be done in order to capitalize on these opportunities? Using our illustration above, it would be impossible to expect physicians to dedicate 80 hours per month to direct care coordination activities. Transitioning to the CCM model of care will require rethinking how care is delivered and moving away from physician-led care to physician-led care teams.

CLA has extensive experience in analyzing the reimbursement implications associated with CCM services and physician-led clinical care teams. We have the operational expertise to guide your organization through assessment to implementation. If you want to learn more and are ready to take the next steps, CLA can help your organization make this important transformation.

Read more.

The Centers for Medicare and Medicaid Services (CMS) has issued its initial plan for medical review of the home health face-to-face (F2F) encounter requirement.  

CMS will conduct prepayment reviews of home health claims using a "Probe and Educate Review" process beginning Oct. 1, 2015. These reviews will impact claims with a "from" date beginning Aug. 1, 2015.  

The purpose of this Probe and Educate process is to ensure that home health agencies understand the new patient certification requirements.  

Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about October 1, 2015. 

CMS plans to provide additional details and information on the Probe and Educate process in the near future. 

Two LeadingAge members -- Presbyterian Villages of Michigan and Williamsburg Landing -- are relying on help from partners to expand their offering of in-home services.

Presbyterian Villages: Home Health Joint Venture

Presbyterian Villages of Michigan (PVM), a LeadingAge member in Southfield, MI, has formed a joint venture with Homestead Home Health Care, Inc. 

The joint venture company will serve PVM residents as well as the older adults living in their own homes in an 8-county area. For the past 5 years, Homestead has been providing services to residents of The Village at Westland, a PVM community in Westland, MI.

The for-profit Homestead will be the new company’s general manager. A representative of PVM will chair the new venture’s governing board, according to Crain’s Detroit Business.

PVM operates 25 senior living communities across Michigan. In addition, it provides community-based health care and other services to older adults living near two PACE (Program of All-Inclusive Care for the Elderly) programs that PVM operates in partnership with Henry Ford Health System.

"We see this as an area of tremendous unmet needs," said PVM President and Chief Executive Officer (CEO) Roger Myers. "We know seniors by and large want to remain in their homes. We think through this joint venture we can meet part of that demand."

Williamsburg Landing: Home Health and Hospice

Williamsburg Landing, a LeadingAge member in Williamsburg, VA, will soon be operating its own home health and hospice program for Williamsburg Landing residents and older consumers living in the Williamsburg area.

The continuing care retirement community (CCRC) has chosen Senior Options, LLC to guide it through the expansion. Senior Options provides advisory services and operational support to senior living organizations. It is a subsidiary of Westminster-Canterbury on Chesapeake Bay, a LeadingAge member in Virginia Beach, VA.

“This is a great opportunity for our independently run retirement communities to work together to serve older adults at home,” said Steve Montgomery, president and CEO of Williamsburg Landing. “Williamsburg Landing’s strategy is to improve the continuum of care that our residents have access to and strengthen their ability to remain in their homes for as long as possible.”

Partnerships are not new to Williamsburg Landing, according to The Virginia Gazette. The CCRC is currently collaborating with Riverside Health System to launch a home-based continuing care program called “ChooseHome.”

Current federal law protects the financial interests of spouses of certain Medicaid beneficiaries by allowing the spouse of a nursing facility resident to keep a minimum share of the couple’s combined income and assets.

Section 2404 of the Patient Protection and Affordable Care Act (PPACA) addresses the institutional bias that applies these spousal protections only to nursing home residents by extending the protections to spouses of Medicaid beneficiaries who receive home and community-based services. 

On May 4, the National Council on Disability (NCD) released "Transportation Update: Where We’ve Gone and What We’ve Learned," a new report offering a comprehensive assessment of surface transportation for people with disabilities. 

The report is a follow-up to the NCD’s 2005 publication, “The Current State of Transportation for People with Disabilities in the United States,” which led, in part, to major improvements in accessible transportation.

The new report outlines both the progress made in the last decade and details the persistent barriers that remain. 

More people with disabilities are riding public transit than ever before and yet in many areas, significant barriers to ground transportation for Americans with disabilities remain pervasive.  

NCD’s report also makes recommendations to policymakers to address these barriers.

Key Transportation Findings 


  • Taxi Alternatives: Emerging transportation models like Uber, SideCar, and Lyft have vigorously resisted regulations typically imposed on the taxicab sector, harming the taxi industry and evading requirements that serve the public interest, including deficits in service to people with disabilities. Uber openly claims it is not covered by the ADA.
  • Fixed Route Buses: Ridership of fixed route bus transit and rail systems by people with disabilities has grown far faster than ridership on ADA para-transit.
  • Para-transit: There have been great gains in best practices in the areas of eligibility, telephone hold time, on-time performance, no-show policies, and origin-to-destination service, but they are often not implemented.
  • Rural Transportation: Minimal or non-existent transit service in rural and remote areas still creates serious barriers to employment, accessible health care, and full participation in society.
  • Rail Transit: Amtrak has lagged behind in meeting ADA requirements for its stations, platforms, train cars, reservations practices, and communications access.


The report noted that the states of Oregon, Iowa, and Maine provide examples of positive coordination of transportation programs for people with disabilities.  

Many cities still lack adequate wheelchair accessible taxi programs, despite progress in some locations, including Chicago, New York, and Rhode Island.


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