Chronic Care Management

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Beginning January 1, 2015, the Medicare Physician Fee Schedule (PFS) reimburses qualified providers for Chronic Care Management (CCM) services for Medicare beneficiaries with two or more chronic health conditions. Pharmacists can participate in CCM as clinical staff, with their services being billed incident to by a qualified provider. CCM services include five core activities:

  • Recording structured data in the patient’s health record;
  • Maintaining a comprehensive care plan for each patient;
  • Providing 24/7 access to care;
  • Comprehensive care management; and
  • Transitional care management.

The Centers for Medicare & Medicaid Services (CMS) estimates that approximately two-thirds of Medicare patients have two or more chronic conditions, and CCM aims to better coordinate the care these patients receive. Through CCM and complex CCM, CMS pays for non-face-to-face care coordination services furnished to Medicare beneficiaries who reside in the community setting that meet the following requirements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient;
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; and
  • Comprehensive care plan established, implemented, revised, or monitored.

CCM could be a powerful base payment mechanism for pharmacists and their prescriber partners who are collaborating on the care of a patient population. Additionally, CCM and complex CCM could provide the fee-for-service mechanism for pharmacists to be compensated for some of their services as pharmacists and physicians enter into emerging quality-based and risk-sharing payment structures.

APhA collaborated with two Quality Improvement Organizations, Health Quality Innovators and Delmarva Foundation, to create Chronic Care Management (CCM): An Overview for Pharmacists. This guide describes the requirements for CCM and how pharmacists may play a role as clinical staff.

CCM in Practice. Learn about how Michelle Thomas, pharmacist at Chickahominy Family Physicians in Virginia, has integrated CCM into her pharmacy practice.

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