Chronic Care Management Software
Transforming Chronic Care Through Innovation
Humhealth provides best-in-class easy to use chronic care management services. Our platform ensures the successful completion of all activities ranging from identifying and enrolling the right patients, all the way to being reimbursed after the end of a care cycle. … Read More
For clinicians, it allows them to add other care team members, engage in two-way communication, assess patients remotely, create and personalize care plans, monitor the patient’s condition, and not worry about tracking time for all relevant chronic care management services provided.
For patients, it ensures that they stay connected with the rest of their care team, receive instructions and educational materials remotely, and track their lifestyle which includes adhering to the right diet, nutrition and medications.
Any reimbursable chronic care management services or activities are automatically captured by the timer that is built into our platform. This includes the time spent by clinicians and their team defining a chronic care management plan and conducting non-face-to-face follow-up calls every month.
Web App Features
Humhealth provides a seamless experience when it comes to chronic care management services. Some of the key features include comprehensive and personalized care plan for each patient, disease specific questionnaire for common chronic conditions, synchronization of patient self-assessment data from mobile app and current month status dashboard. The Continuity of Care Document (CCD) Upload and EMR Integration are also done at affordable pricing.
Personalized care plan for each patient
Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing
Two way communication with patient through Text Message
Continuity of Care Document Upload and EMR Integration
Feature to initiate Video Call
VOIP Integration with multiple vendors
HIPAA compliant Fax integration
Synchronization of patient self-assessment data from Mobile app
Automated Time Tracker
Define Care Team Members
Comprehensive Monthly Service Summary
Comprehensive Scheduling Feature
CCM Current Month Status Dashboard
Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications
Disease-specific questionnaire for common chronic diseases
Questionnaire Configuration at facility and patient levels
Mobile App Features
Patient and Physician mobile app
24/7 access to care plan by patient
OTC Medication
Physical activity tracking
Record symptoms
View the training session recording
View newsletter and educational material
Calorie tracker
Feature to attend a Video call
View call summary
CCM Workflow
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1
Identify Eligible Chronic Patients
Clinicians identify eligible patients with chronic diseases using his/her patient list … Read More -
2
Enroll The Patient
On identifying the patients with two or more chronic conditions, the clinicians will enroll … Read More -
3
Define A Care Plan
Based on the patient’s health records, the Clinicians will formulate a suitable care plan … Read More -
4
Monthly CCM
The Clinician will have a monthly follow up call with the Patient to provide CCM service. -
5
Track Time
During the non-face-to-face interaction by a Clinician with the Patient, the … Read More -
6
Timely Reimbursement
Most would accept that the tedious part of CCM is getting a reimbursement … Read More
Billing Codes
We cover an extensive list of chronic care management billing codes that make up both complex and non-complex chronic care for hospitals, private practices, rural health clinics and federally qualified health centers-
CPT 99490
- Chronic care management services provided by clinical staff and directed by a physician or other qualified health care professional (Non-Complex)
- Duration 20 minutes
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$62
Average Reimbursement
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CPT 99439
- Add-on code – first increment (non-complex CCM)
- Duration 20 minutes
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$47
Average Reimbursement
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CPT 99491
- Chronic care management services, provided personally by a physician or other qualified health care professional
- Duration 30 minutes
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$83
Average Reimbursement
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CPT 99437
- Add-on Code for Chronic Care Management services, provided personally by a physician or other qualified health care professional
- Duration 30 minutes
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$59
Average Reimbursement
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CPT 99487
- Complex services provided by clinical staff and directed by a physician or other qualified health care professional
- Duration 60 minutes
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$103
Average Reimbursement
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CPT 99489
- Add-on code for Complex CCM Service
- Duration 30 minutes
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$68
Average Reimbursement
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CPT G0511
- CCM Service for Rural Health Clinic (or) Federally Qualified Health Center
- Duration 20 minutes
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$67.03
Average Reimbursement
At a time when the world shifts to value-based remote care, we are on standby to support any healthcare organization set up and run their Chronic Care Management operations. Chronic care fits well with other types of reimbursable programs mentioned in our website. If you have any questions, please do email us or use the chat feature. If you are ready to get started, please sign up for a demo.
FAQ
Medicare patients with at least two or more chronic diseases that
are expected to be present for at least 12 months or until death of
the patient.
Advance consent for CCM services may be verbal or written. If the
consent is verbal, there should be documentation in the electronic
health record reflecting this.
There are a wide range of services that can be provided under CCM
for Medicare beneficiaries with multiple chronic conditions.
- Care management and transitional care management services
- Communicating with the Medicare beneficiary in person, by phone, or electronically for care coordination
- Community resource referral and linkage
- Coordinating community and social support service
- Medication management
- Symptom management
- Preventive health counselling
- Health coaching
Regular CCM covers 20 minutes of clinical staff time per month for
ongoing oversight, management, and care planning.Complex CCM
places the patient at significant risk of death. Minimum of 60
minutes of Clinical staff time is required with substantial
revision of care planning and moderate to high complexity in
medical decision making. All CCM services (regular and complex)
must be provided under the supervision of a physician or
non-physician provider (nurse practitioner or physician
assistant).
The care plan should include the details of the following
elements:
- Problem list detailing the chronic conditions the patient suffers from
- Expected outcome and the likely course of the disease
- Measurable treatment goals
- Symptom management
- Planned interventions through regular follow-ups and vital data collection from patient
- Medication management depending on any concerns/reactions/improvement reported by the patient
- Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc.
- Requirements for periodic review and revision of the care plan is required.
Yes. CMS requires the care provider to share the care plan with
the patient in a written or electronic format.
CMS has stated the transmission has to be electronic. Facsimile
transmission does not satisfy the requirement.
Chronic Care Management
During any given month, a Medicare beneficiary can receive CCM or
complex CCM, but NOT both. Only one qualified provider entity can
bill for CCM services each month.
Remote Patient Monitoring | Remote Patient Monitoring Software | Chronic Care Management
The CCM service period is one calendar month. Practitioners
may report CCM at the conclusion of the service period, or after
completion of the minimum required service time.
Chronic care managements services can be billed if the beneficiary
dies during the service period, as long as at least 20 minutes of
qualifying services were furnished during that calendar month and
all other billing requirements are met.
Physicians and Non-Physicians can claim reimbursement by billing
for CCM CPT Codes. CCM code is most likely to be billed by primary
care physicians. However, specialists, nurse practitioners,
physician assistants, clinical nurse can also bill CCM.
