Chronic care management in the urologic oncology setting

The widespread use of telemedicine due to the coronavirus disease 2019 (COVID-19) pandemic has expanded the use of chronic care management beyond the primary care setting. The Centers for Medicare & Medicaid Services (CMS) recognized that chronic care management (CCM) contributes to better health and care for the individual and can result in reduced costs. Since 2015, Medicare has paid separately for CCM services furnished to patients with multiple chronic conditions. Medicare uses the Current Procedural Terminology (CPT) code 99490.¹

Evan R. Goldfischer, MD

Chronic care management is not simply making a telephone call to a patient. It is an extensive service that includes structured recording of patient health information, an electronic care plan addressing all health issues, access to care management services, management of care transitions, and coordination and sharing of patient information with practitioners and providers outside the practice.

A natural extension of telemedicine

Urologists were slow to use chronic care management services, but with the rise of telemedicine in March 2020, CCM seems to be a natural extension of telemedicine. This is especially true when caring for urology oncology patients, who may be required to follow up for multiple examinations, radiological tests, and to ensure compliance with medications, and monitor monitoring of side effects of treatments.

Chronic care management using the CPT code 99490 (no it is 99490) requires at least 20 minutes of clinical staff time directed by physician or other qualified health professional per calendar month. It also is required that there must be 2 or more chronic conditions expected to last 12 months or until the death of the patient; the chronic conditions must place a patient at significant risk of death, acute exacerbation, decompensation, or functional decline; and the comprehensive care plan must be established, implemented monitored, and revised as needed.

Examples of chronic conditions include, but are not limited to:

• Alzheimer disease and related dementia,

• arthritis (osteoarthritis and rheumatoid),

• asthma,

• atrial fibrillation,

• autism spectrum disorders,

• cancer,

• cardiovascular disease,

• chronic obstructive pulmonary disease,

• depression,

• diabetes,

• hypertension, and

• infectious diseases such as HIV/AIDS.²

CPT code 99491 requires at least 30 minutes per month a physician or other qualified health care professional time. CPT code 99487 requires at least 60 minutes of clinical staff time directed by physician or other qualified health care professional per calendar month. CPT code 99489 should be use for each additional 30 minutes of clinical staff time directed by physician or other qualified health care professional per calendar month.

Unlike telemedicine, a broad range of clinicians can provide chronic care management services. This list includes:

• physicians,

• nurse practitioners,

• physician assistants,

• nurse midwives,

• clinical nurse specialists,

• certified registered nurse anesthetists,

• clinical psychologists,

• clinical social workers, and

• registered dietitians or nutrition professionals.³

In order to establish a relationship for chronic care management, the patient must give consent for a practitioner to provide CCM services. Only 1 practitioner may be paid for chronic care management services per given calendar month. The patient does reserve the right to change practitioners each month. It is important for the urologist to remember that if the primary care doctor is already using the code, then the urologist may not do so during the same month.

There also is no double dipping. For example, if a patient is already enrolled in a program such as Comprehensive Primary Care Plus through their primary doctor, then they cannot be enrolled in chronic care management. Most practices will have a chronic care manager to implement this service line. For practices that have an advanced prostate cancer clinic or an advanced bladder cancer clinic, the nurse navigator is an ideal person to also be the chronic care manager. This individual can ensure the patient is eligible, obtain consent, document the conversations and care plan for each call, and check that there is physician oversight for issues that come up on the phone calls. This may be different from the typical advanced prostate cancer clinic, where the care plan is not always clearly delineated, and patients are not always on a specific visit schedule.

Many cancer patients have a second chronic condition managed by the urology team or the nurse navigator, under the direction of the urologist, who can coordinate care with another specialist such as a cardiologist or endocrinologist. An example of how to implement a CCM program in an advanced prostate cancer clinic would be to have the nurse navigator ensure that all laboratory and imaging tests are performed as scheduled, send appointment reminders, ensure pill compliance and monitor medication side effects, and address complications in real time in order to avoid emergency room visits. They also can assess for pain and look at a patient’s overall health and refer to the appropriate provider. The nurse navigator would review the patient’s results with the urologist to provide oversight and adjust the care plan.

Chronic care management does not have to have a video component, as CMS has ruled that audio communication by itself is sufficient. Typically, telemedicine does have to have a video component; however, this requirement has been waived during the COVID-19 pandemic.

Chronic care management should be viewed as a subservice of telemedicine. It can engage multiple providers in the care of a patient with at least 2 chronic conditions to monitor compliance and outcomes, while reducing the number of in-person visits normally required.⁴

Goldfischer is director of research, urology division, Premier Medical Group, Poughkeepsie, New York, and clinical assistant professor of urology, New York Medical College, Valhalla, New York.

References

1. Chronic care management services. Centers for Medicaid & Medicaid Services. July 2019. Accessed July 29, 2020. ​ https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf​

2. Pelosi R. Chronic care management: Delivering effective, profitable services. Medical Economics. 2020;96(14):22-26

3. Bazzano AN, Wharton MK, Monnette A, et al. Barriers and facilitators in implementing non-face-to-face chronic care management in an elderly population with diabetes: a qualitative study of physician and health system perspectives. J Clin Med. 2018;7(11):451. doi:10.3390/jcm7110451

4.Boehmer KR, Abu Dabrh AM, Gionfriddo MR, Erwin P, Montori V. Does the chronic care model meet the emerging needs of people living with multimorbidity? A systematic review and thematic synthesis. PLoS One. 2018;13(2):e0190852. doi:10.1371/journal.pone.0190852