1. Chronic Care Management
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2. THE PROBLEM
Chronic diseases and conditions, including heart disease, diabetes, COPD and obesity, are among the most
common, expensive, and preventable health problems in the United States. About half of the adults in
America, 117 million people, have at least one chronic condition.
Research consistently shows that effective chronic care management reduces the costs of care for
chronic disease patients while improving their overall health. However, providers have not been
reimbursed for non face-to-face care coordination services.
Chronic disease patients are often left to coordinate between-visit care for themselves, creating huge
gaps in communication, and resulting in fragmented health data, duplicated tests, increased healthcare
expenses, and a higher likelihood of poor health outcomes.
THE OPPORTUNITY
The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of Chronic Care
Management (CCM) and the impact that it has on healthcare expenses and outcomes, and has started
paying monthly reimbursements for care coordination services.
New for 2015, Current Procedural Terminology (CPT®)2
code 99490 pays approximately $43 per month3
to
providers who deliver 20+ minutes of non face-to-face chronic care coordination to eligible Medicare
beneficiaries with 2 or more chronic conditions.
These services can be fulfilled by the provider or performed by a subcontractor.
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IN THE UNITED STATES
CAUSES OF DEATH IN 2010 WERE CHRONIC ILLNESSES1
7of the TOP 10
GOES TO THE TREATMENT OF CHRONIC ILLNESS
2/3of Medicare dollarsARE SPENT ON PATIENTS WITH 5+ CHRONIC CONDITIONS.
1
http://www.cdc.gov/chronicdisease/overview/
2
CPT®
is registered trademark of the American Medical Association
3
$42.60 per month is the national average. Actual amounts will vary by region

3. In order to bill Medicare, providers must meet several new technology and services requirements for
creating and sharing comprehensive care plans with the patient and all of the patients’ providers.
CPT 99490
The Final Rule of the 2015 Medicare Physician Fee Schedule included the new CPT 99490, defined as:
REQUIREMENTS
CMS has listed specific requirements in order for providers to bill CPT 99490. They include:
✓✓24/7 access to clinical staff to address urgent
chronic care needs
✓✓Continuity of care through access to an
established care team for successive routine
appointments
✓✓Ongoing care management for all chronic
conditions, including medication reconciliation
and the regular assessment of a patient’s
medical, functional, and psychosocial needs
✓✓A comprehensive, patient-centered health
summary and care plan that includes all current
records from all the patient’s providers
✓✓Management of care transitions between and
among all providers and settings using electronic
transmission of information
✓✓Coordination with home- and community-based
clinical service providers
✓✓Patient and caregiver access, with enhanced
opportunities for all relevant caregivers to
communicate about the patient’s care
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“Chronic care management services, at least 20 minutes of clinical staff
time directed by a physician or other qualified health care professional, per
calendar month, with the following required elements; multiple (two or
more) chronic conditions expected to last at least 12 months, or until
the death of the patient; chronic conditions place the patient at significant
risk of death, acute exacerbation/decompensation, or functional decline;
comprehensive care plan established, implemented, revised, or monitored.”
(CMS Final Rule, October 31, 2014)

4. Eligible Providers
CMS’ intent was to have primary care coordinate, but the code allows for any provider to perform the
services. While the billing provider must oversee the CCM services, they are not required to be present for
the work to be done.
Physicians, regardless of specialty, advanced practice registered nurses, physician’s assistants, clinical nurse
specialists, and certified nurse midwives are all eligible to bill Medicare for CCM. Non-physician and limited-
license practitioners, such as clinical psychologists and social workers, are not eligible to bill for CCM.
To date, Medicare has not recognized CCM as a rural health clinic (RHC) or federally qualified health center
(FQHC) service. We expect this to change for 2016.
Only one provider may bill per calendar month.
Eligible Patients & Chronic Conditions:
CMS has left the ruling open to discernment by the provider. The guideline simply requires:
✓✓Two or more chronic conditions expected to last at least 12 months, or until the death of the patient
✓✓Chronic conditions that place the patient at significant risk of death, or acute exacerbation/
decompensation
CMS maintains a Chronic Condition Warehouse (CCW)4
with 22 chronic conditions listed to provide
researchers with beneficiary, claims, and assessment data, however, it is not an exclusive list.
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Physicians, regardless
of specialty, advanced
practice registered nurses,
physician’s assistants,
clinical nurse specialists,
and certified nurse
midwives are all eligible to
bill Medicare for CCM.
4
https://www.ccwdata.org/web/guest/medicare-charts/medicare-chronic-condition-charts

5. PREVALENT HEALTH CONDITIONS AMONG HIGH-RISK PATIENTS
SO YOU WANT TO PROVIDE CCM FOR YOUR PATIENTS?
Consent
In order to bill for CCM, providers must get the patient’s written consent, confirming that the following has
been explained to the beneficiary:
✓✓An overview of CCM
✓✓How the CCM service may be accessed
✓✓That only one provider can provide CCM services
at a time
✓✓That information will be shared among all the
patient’s providers
✓✓The patient can terminate the CCM service at any
point in time by revoking consent
✓✓The patient will be responsible for any associated
copayment or deductibles
Once the consent form is signed, a copy must be stored in the patient’s medical record.
If a patient chooses to revoke consent, providers may not bill for CCM after the month the revocation was
made. If the 20+ minutes of CCM has already been completed, providers may bill for that month.
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5
Source: November 2014 Healthcare Performance Benchmarks: Stratifying High-Risk Patients
Diabetes
Hypertension
Mental Health
Congestive Heart Failure
Chronic Obstructive
Pulmonary Disease
Other
Cardiac Arrhythmia
Vascular
End Stage Renal Disease
Acute Myocardial
Infarction/Infraction
37.5%
20.0%
15.0%
10.0%
5.0%
5.0%
2.5%

6. Certified EHR
Any provider billing for CCM is required to use technology, which for 2015, includes an EHR that satisfies
the 2011 or 2014 criteria of the EHR Incentive Program.
The Care Plan
At the core of the code, providers must maintain a regularly updated, electronic Care Plan that is based
on an assessment of the patient’s needs. The plan should include all of the patient’s healthcare providers,
family & caregivers, all health conditions (not just those considered chronic), and be aligned with the
patient’s choices and values.
CMS has included the following items as recommendations to be included in the patient’s comprehensive
Care Plan:
✓✓Comprehensive problem list including expected
outcome and prognosis and measurable
treatment goals
✓✓Symptom management and planned
interventions
✓✓Accessible community and social services
✓✓Plan for care coordination among all providers
✓✓Medication management, including current
medication list and allergies, reconciliation, and
oversight of patient self-management
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Because of this, CMS
includes that providers
“must have flexibility to
use a wide range of tools
and services beyond
EHR technology now
available in the market
to support electronic
care planning.”

7. ✓✓Designated person responsible for each
intervention
✓✓Any requirements for regular review/revision
CMS requires that the care plan must be created using some form of electronic technology, but recognizes
that current EHR technology is limited in its scope to support electronic Care Plans.
Because of this, CMS includes that providers “must have flexibility to use a wide range of tools and services
beyond EHR technology now available in the market to support electronic care planning.”
There are three requirements regarding electronic access to the patient’s care plan:
✓✓All care team members must have 24/7 electronic access to the care plan
✓✓The billing provider “must electronically share care plan information as appropriate with other
providers” who are providing care for the patient
✓✓The billing provider must provide a paper or electronic copy of the care plan to the patient.
Additional Requirements
In order to bill for CCM, providers must offer 24/7 access to a member of the care team to address
urgent chronic care needs and facilitate care coordination, including successive routine appointments
and enhanced opportunities for patient/caregiver-provider communication, such as Direct messaging or
in-app communication.
Billing providers must facilitate all transitions of care, including follow-up with a patient after a visit to the
ER and post-discharge transitional care management (TCM) services6
. Additionally, providers furnishing
CCM are required to coordinate referrals to other providers, as well as to share up-to-date information
electronically with all the providers on a patient’s care team.
Lastly, providers must have the ability to coordinate care with home- and community-based providers, including
home health, hospice, nutrition services, outpatient therapies, and transportation services, to name a few.
Any communication with these service providers must be documented in the CCM-certified technology.
CHRONIC CARE MANAGEMENT WITH CARESYNC
The new Chronic Care Management code creates new opportunities for added revenue and enhanced
patient care. However, caution must be taken to be certain that billing providers are compliant with the
billing requirements for 99490.
Many providers throughout the United States are looking for ways to offer this proven, effective benefit for
their patients, while adding in a new stream of revenue.
The strict billing requirements of CMS’ Chronic Care Management initiative are at the very core of what
CareSync has been doing for years. The unique combination of industry-leading technology and care
coordination services creates a turnkey, care management solution to provide CCM for your practice.
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Providers may not bill for TCM and CCM at the same time.

8. Providers who choose CareSync’s Chronic Care Management are effortlessly equipped to offer patients and
their families the most comprehensive care coordination solution available.
How does it work?✓✓✓
✓ Health Assistants collect medical records from all
a patient’s providers to build a comprehensive
Care Plan and health summary that includes the
CMS-required elements.
✓ Health Assistants spend a minimum of 20
minutes per patient, per month assisting with
care coordination tasks including scheduling
medical visits, reconciling medication lists,
updating care plans, tracking adherence and
more.
✓ Health Assistants are available 24/7 by phone,
online, and through in-app messaging to help
patients with acute chronic care issues and care
coordination tasks.
✓✓CareSync’s Health Assistants facilitate care
transitions, document the information, and
keep all members of the care team up-to-date.
✓✓Every medical visit is recorded, and every
provider has access to the documentation via
the free CareSync application and care team
updates. True care coordination.
✓✓CareSync offers the revolutionary ability for
families to access & interact with information,
share it before visits, listen to a recording
of the doctor’s instructions, and respond
to notifications when a reminder is missed.
CareSync is a true family health record.
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CareSync’s industry-leading
technology and care coordination
services turn an overwhelming
process into an opportunity to
greatly improve your patients’
experiences and medical
outcomes, with a positive impact
on your bottom line.

9. In addition to meeting all of Medicare’s requirements for CCM, CareSync goes above and beyond. Here are
a few of the additional benefits you and your patients receive with CareSync:
✓✓Our trademarked Health Timeline™ is an important part of your patient’s history, as well as the care
team’s understanding of what has been done lately. The most recent 30 days of Timeline activity is
included with the monthly update sent to all current providers.
✓✓Free Caregiver Accounts - The patient’s family members and other caregivers not only have access to
the patient’s information, they are encouraged to create their own free accounts to be truly engaged
with the application.
✓✓Medication & measurement instructions & reminders are part of every Care Plan, but CareSync turns
it into an engaging opportunity to generate useful data and complete the communication loop with the
providers.
✓✓Visit planning tools make it easy for patients and caregivers to plan the visit by adding notes and
tasks that are transmitted to the provider before the visit. A voice recorder built into the app allows the
doctor’s explanations and instructions to be saved.
✓✓Integrations with tracking and wearable devices make it nearly effortless for patients to collect critical
between-visit data.
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CareSync’s industry-leading technology and care coordination services turn an overwhelming process into
an opportunity to greatly improve your patients’ experiences and medical outcomes, with a positive impact
on your bottom line.
CareSync will provide the turnkey service and a summary at the end of each month. You bill Medicare each
month, and pay only for the CareSync service. The CareSync platform is also available as a software-only
option.
Getting started is simple:
We know you’re busy. CareSync ensures that you benefit from this revenue-generating opportunity
without adding to your expenses or making any changes to your current workflow. CareSync is designed to
work with your current technology, and your dedicated Implementation Manager will guide you through
the simple setup in just a few minutes.
Visit us online at www.caresync.com/ccm, or talk to one of our Chronic Care Management experts by
calling 813-658-3749.
LEARN MORE

10. CALL US AT 813.658.3749
FOR INQUIRIES CONTACT CCM@CARESYNC.COM
VISIT US TODAY AT WWW.CARESYNC.COM/CCM