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Why CCM?

What’s the problem?

99% of all Medicare spending is on patients with chronic conditions.

Two- thirds of Medicare beneficiaries have 2+ chronic conditions.

Racial and ethnic minorities receive poorer care than whites on 40% of quality measures, including chronic care coordination and patient- centered care.

People are not aware of the extent to which their own actions can affect their health and wellbeing, longevity and overall quality of life.

84% of national healthcare spending is on people with chronic conditions. Some examples of chronic conditions are Diabetes, Hypertension and Depression.

Half of all Americans have a chronic condition- 117 million people

People do not have sufficient knowledge and understanding about their chronic conditions and the lifestyle changes needed to address those chronic conditions.

What’s the solution?

You can help by letting Well Connect MDs help you!

 Utilize the available CCM codes: CPT 99490, 99487, 99489, 99091 and HCPCS code GO506, and be part of a team of health professionals who are all working towards the same goal of helping patients achieve better health, whilst simultaneously benefitting from recurring monthly revenue for your Practice.

 Be an advocate for health promotion by enrolling your patients into our CCM program so they can be given the knowledge and education they need about their chronic conditions, and encouraged to make those small changes that have a huge impact on their health and wellbeing now and in the future.

Be a champion for better care-coordination. We establish patient- centered care plans that address all aspects of a person’s health care needs and that set achievable, realistic goals so that a patient’s progress can be systematically tracked over time by the patient and by the health professionals in a collaborative manner.

Let us provide enhanced communication opportunities for your patients, not only via telephone but also through the use of secure messaging, Internet and remote patient monitoring.

We provide 24/7 access to clinical staff so your patients and caregiver’s needs can be addressed regardless of the time of day or day of the week.

Let Well Connect MDs be the extra pair of eyes looking out for your patients!

New Rules Make It Easier!

Six service elements were improved in January 2017, including, initiating visit, 24/7 access to care and continuity of care, comprehensive care plan, management of care transitions documentation, home and community-based care  coordination and beneficiary consent

Only new patients or patients not seen within one year prior are required to have an initiating visit for CCM services. The initiating face-to-face visit is no longer required for existing patients who have been seeing within the last year.

Beneficiary consents may be either verbal or written provided it is documented in the medical record.

24-hour access to the patient's electronic care plan is no longer needed. CMSwill allow fax to count for electronic transmissions of clinical summaries and the care plan.

Home and community-based care coordination communications must be documented in the patient's medical record, but the requirement to do so in a certified electronic health record has been removed.

Care transitions documentation will be referred to as continuity of care documents instead of clinical summaries. Formatting of this document as well as how it is transmitted to the providers is no longer regulated and may now be faxed.

Providers may choose the format in which the care plan is provided to patients. Care plan information must be captured electronically (can include fax) and be shared in a timely manner within and outside the billing Practice as appropriate to those involved in the patient's care.

A Brief History:

January 1st 2015 Medicare started issuing payments for Chronic Care Management services under CPT 99490

CPT 99490: (20 minutes of non-face-to-face time/10 coordination for Medicare patients with two or more chronic health conditions.)

Doctors complained that the service and billing requirements were too complex and that the payment for the code wasn't sufficient to cover the costs of delivering the service

January 1, 2017 Medicare  introduces crucial changes to the billing requirements, including new codes for complex CCM

CPT 99487: (complex chronic care management services with 60 minutes of clinical staff time directed by a physician or other qualified healthcare professional, per calendar month, for moderate or high complexity medical decision-making.)

CPT G0506: (comprehensive assessment of and planning by the physician or other qualified healthcare professional for patients requiring chronic care management services, billed separately from monthly care management services.

CPT 99489: (each additional 30 minutes of clinical staff time as an add on item to CPT 99487

Requirements for billing CCM Services


  1. Structured recording of patient information using certified EHR technology:


Structured recording of demographics, problems, medications and medication allergies.


A full list of problems, medications and medication allergies in the EHR must inform the care plan, care- coordination and ongoing clinical care.



  1. Provide 24/7 access:


Provide 24/7 access to physicians or other qualified healthcare professionals or clinical staff including providing patients/caregivers with means to make contact with healthcare professionals in the practice to address urgent needs regardless of the time of day or day of week.


Continuity of care is to be established with a designated member of staff, with whom the patient is able to schedule successive routine appointments.


Care management for chronic conditions including systematic assessment of the patient’s medical, functional and psychosocial needs; with system based approaches to ensure all preventative care services are received in a timely manner.

  1. A comprehensive care plan:


A comprehensive care plan must be created, revised and monitored in electronic format, based on physical, mental, cognitive, psychosocial, functional and environmental (re) assessment. It must include details of the patient’s support network and available resources.


The care plan information must be available to everyone involved in the patient’s care in a timely manner both within and outside of the billing practice.


A copy of the care plan must be given to the patient and/or caregiver.


  1. Management of care transitions:


Management of care transitions between and among health care providers, including referrals and follow up after ER visits, discharges from hospitals, and nursing facilities will be achieved using a continuity of care document (formerly the clinical summary.)


Continuity of care documents must be exchanged in a timely manner with all the health care providers involved as necessary.


  1. Enhanced communication opportunities:


Enhanced communication opportunities must be available to patients and caregivers to communicate with the practitioner not only via telephone but also through the use of secure messaging, Internet or other non face to face methods.

  1. Initiating visit:


Initiation to Chronic Care Management services during an Annual Wellness Visit (AWV), Welcome to Medicare or Initial Preventative Physician Examination (IPPE), or face to face E/M visit (Level 4 or 5 visit is not required), for new patients or patients seen within 1 year prior to commencement of CCM services.


The new CPT code GO506 may also be billed with the start or initiation of CCM services. This code should only be billed if the time and effort involved in the care plan development is beyond the usual time and effort involved in the underlying E/M service. Also, the code can only be billed once, at the outset of CCM services. The time and effort involved in revising a patient’s care plan is still not separately reimbursed.


  1. Beneficiary Consent:


The patient needs to be informed that only one practitioner can furnish and be paid for these services during a calendar month; as well as their right to stop the CCM services at any time (effective at the end of the calendar month.)


It must be documented in the patient’s medical record that the required information was explained and whether the patient accepted or declined the services.

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