Web App Features

  • Personalized care plan for each patient

    Personalized care plan for each patient

  • Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

    Tracking Physician and Clinician time separately and Utilizing Optimal CPT code for billing

  • Two way communication with patient through Text Message

    Two way communication with patient through Text Message

  • Continuity of Care Document Upload and EMR Integration

    Continuity of Care Document Upload and EMR Integration

  • Feature to initiate video Call

    Feature to initiate Video Call

  • VOIP Integration with multiple vendors

    VOIP Integration with multiple vendors

  • HIPAA compliant Fax integration

    HIPAA compliant Fax integration

  • Synchronization of patient self-assessment data from Mobile app

    Synchronization of patient self-assessment data from Mobile app

  • Automated Time Tracker

    Automated Time Tracker

  • Define Care Team Members

    Define Care Team Members

  • Comprehensive Monthly Service Summary

    Comprehensive Monthly Service Summary

  • Comprehensive Scheduling Feature

    Comprehensive Scheduling Feature

  • CCM Current Month Status Dashboard

    CCM Current Month Status Dashboard

  • Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

    Customize Questionnaire for tracking Goals, Lifestyle Recommendations and Medications

  • Disease-specific questionnaire for common chronic diseases

    Disease-specific questionnaire for common chronic diseases

  • Questionnaire Configuration at facility and patient levels

    Questionnaire
    Configuration at
    facility
    and patient levels

Mobile App Features

  • Patient and Physician mobile app

    Patient and Physician mobile app

  • 24/7 access to care
              plan by patient

    24/7 access to care plan by patient

  • OTC Medication

    OTC Medication

  • Physical activity
              tracking

    Physical activity tracking

  • Record symptoms

    Record symptoms

Humhealth Mobile app
  • View the training
              session recording

    View the training session recording

  • View newsletter and
              educational material

    View newsletter and educational material

  • Calorie tracker

    Calorie tracker

  • Feature to attend a
              Video call

    Feature to attend a Video call

  • View call
              summary

    View call summary

CCM Workflow

  • workflow 1

    1

    Identify Eligible
    Chronic Patients

  • workflow 2

    2

    Enroll the
    Patient

  • workflow 3

    3

    Define a
    Care Plan

  • workflow 4

    4

    Monthly CCM
    Non-Face to
    Face follow up
    call

  • workflow 5

    5

    Track Time

  • workflow 6

    6

    CCM
    Reimbursement

Billing Codes

  • 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

  • $42.84

    Average Reimbursement

  • CPT
    99439

  • Add-on code – first increment (non-complex
    CCM)

  • Duration
    20 minutes

  • $38

    Average Reimbursement

  • CPT
    99439

  • Add-on code – second increment (non-complex
    CCM)

  • Duration
    20 minutes

  • $38

    Average Reimbursement

  • CPT
    99491

  • Chronic care management services, provided
    personally by a physician or other qualified health care
    professional

  • Duration
    30 minutes

  • $84

    Average Reimbursement

  • CPT
    99487

  • Complex Chronic care management services provided
    by clinical staff and directed by a physician or other
    qualified health care professional

  • Duration
    60 minutes

  • $94.68

    Average Reimbursement

  • CPT
    99489

  • Add-on code for Complex CCM Service

  • Duration
    30 minutes

  • $47.16

    Average Reimbursement

  • CPT
    G0511

  • CCM Service for Rural Health Clinic (or) Federally
    Qualified Health Center

  • Duration
    20 minutes

  • $67.03

    Average Reimbursement

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.

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.

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 management 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.