Background: The Centers for Medicare & Medicaid Services (CMS) recognizes chronic care management (CCM) as a critical component of primary care that contributes to better health and care for individuals. In 2015, Medicare began paying separately under the Medicare physician fee schedule (PFS) for CCM services furnished to patients with multiple chronic conditions. In 2017, our health system launched a CCM pilot, which was retired within 6 months of implementation due to complicated documentation and billing workflows and poor provider adoption. In 2021 with the release of streamlined electronic medical record (EMR)-based billing and documentation solutions, our system revisited implementation of CCM for our 25,000+ eligible patients.
Objectives: The purpose of this process improvement project (PI) was twofold. Our first objective was to develop, implement, and track CCM services for three distinct markets in Hampton Roads Virginia, Blue Ridge Virginia, and Northeast North Carolina. Our second objective was to create a sustainable and scalable financial model to support continued nursing services in both value-based and traditional fee for services contracts.
Methods: Over a 12-month period the project team comprised of information technology (IT), EMR analysts, billing analysts, nursing leaders, and population health analysts worked to create a streamlined process for provider-based billing (PBB) and non-PBB sites. The team capitalized on the standardized workflows provided by our EMR vendor. Using the out-of-the box solution, the team developed a process in which the RNs utilized a standard visit type in the existing centralized nursing EMR departments to document and bill for CCM services. The new documentation workflows reduced documentation requirement by 50% through elimination of duplicate documentation in two EMR departments. In addition to reducing documentation requirements, the team leveraged new capabilities to automate CCM code selection and charge capture by tracking CCM time spent monthly and complexity in a discreet manner. Lastly, a tableau dashboard was created to track CCM enrollment, billing, and revenue by practice and provider.
Results: In the first nine months of implementation, the centralized nursing teams enrolled 1,055 unique patients in CCM. The 1,055 patients had 4,282 CCM codes charged, resulting in 2,728 work relative value units (wRVUs) and $379,711 in gross revenue. In addition, the case management team saw significant improvements in workflow related to consolidated practice assignments. Based on projected CCM revenue over the next five years, CM (case management) leadership developed a business case and received approval to increase RN full time equivalents by 30%. Based on the current year's revenue projections, CCM revenue will cover 75% of the cost of the additional FTEs. The remaining 25% will be realized through shared savings from reduced medical expense ratios.
Conclusion: As the healthcare landscape continues to move to value-based care, the ability to track and bill nursing work in the ambulatory care setting utilizing traditional billing and wRVU methods alongside value-based outcome measures is critical for sustaining and expanding nursing services. For successful implementation and scaling of CCM programs, documentation and billing workflows need to be automated, streamlined, and discreet.
