CCM - What makes your patients Chronic Care Management eligible? 

Eligible CCM patients will have multiple (2 or more) chronic conditions expected to last at least 12 months or until the patient’s death and or that place them at significant risk of death, acute exacerbation and or decompensation, or functional decline.  

● These services aren’t typically face-to-face and allow eligible practitioners to bill at least 20 minutes or more of care coordination services per month  

● Billing practitioners may consider identifying patients who require CCM services using  criteria suggested in CPT guidance (like number of illnesses, number of medications,  repeat admissions, or emergency department visits) or the typical patient profile in the CPT prefatory language. 

CCM services can also help reduce geographic and racial or ethnic health care disparities Examples of chronic conditions include, but aren’t limited to:  

● Alzheimer’s disease and related dementia  

● Arthritis (osteoarthritis and rheumatoid)  

● Asthma  

● Atrial fibrillation  

● Autism spectrum disorders  

● Cancer  

● Cardiovascular disease  

● Chronic Obstructive Pulmonary Disease (COPD)  

● Depression  

● Diabetes  

● Hypertension  

● Infectious diseases like HIV and AID          

CMS MLN Overview Booklet link: chroniccaremanagement.pdf (cms.gov) 

BH - What Behavioral Health do you provide?

In addition to active use of Social Determinants of Heath, We provide Behavioral Health Integration as part of our Behavioral Health solution.

BH Impacts health in a multitude of ways and one of the most common impacts is protocol and appointment compliance.  SDoH has been shown for years to have a significant impact on overall mental health. 

Sample Tip from the Behavioral Health Booklet .pdf link below:

MLN Booklet Tip: We make separate payment to physicians and non-physician practitioners for BHI services they supply to patients over a calendar month service period. BHI is a type of care management service. In recent years, we expanded the suite of codes describing care management services. New codes describe services that involve:  

● Direct patient contact, in-person or face-to-face services that don’t involve direct patient contact  

● Representing a single encounter, a monthly service, or both  

● Timed services  

● Addressing specific conditions  

● Representing the work of the billing practitioner, auxiliary personnel (specifically, clinical staff), or both 

CMS MLN BHI overview booklet link: 

mln909432-behavioral-health-integration-services.pdf (cms.gov) 

RPM/RTM - How does your RPM work?

We Provide Remote Patient Monitoring services via approved connected devices. Our RNs monitor the feeds for active intervention to avoid adverse outcomes and keep your Practitioner in the loop via direct feed to the their EMR.  Moreover, we follow up with you, the Patient, in the event of monitoring issues.

How is RTM integrated with RPM?

Our services also can include Remote Therapeutic Monitoring/Management to ensure medications are being taken on schedule and in the proper order.

Do you provide other Medication related services?

Yes, our Consultative Pharmacists are available for medication reconciliation, adherence, and high-risk medication monitoring.