Spruce and Chronic Care Management
Spruce and Chronic Care Management

Seven Ways to Provide and Bill for Chronic Care Management on Spruce

The Centers for Medicare & Medicaid Services (CMS) estimates that over two-thirds of Medicare beneficiaries have at least two chronic medical conditions, such as hypertension, hyperlipidemia, or diabetes, and a full 14% of enrollees have six or more such conditions.1,2 That latter set of patients alone accounts for nearly half of total Medicare spending, so it only makes sense that the agency has recently sought to incentivize improved care for its patients with chronic conditions, and it’s doing so through the adoption of a set of Chronic Care Management (CCM) CPT codes.

Since 2015, eligible practitioners have been able to bill Medicare using CPT code 99490, which provides reimbursement for “chronic care management services,” such as maintaining a comprehensive care plan and managing transitions of care between providers, so long as such services were provided to Medicare patients with two or more chronic conditions.3 More recently, the agency has also embraced codes 99487 and 99489, which add support for “complex” CCM and for CCM that requires more time than usual.

The typical reimbursement for CPT code 99490 is about $43 per month per patient, so savvy practices with even modestly sized panels have been able to add thousands of dollars of important revenue each month, simply by correctly reporting services that they’ve already been providing for free for many years.4

The CCM codes are not difficult to use, but they do have important requirements for proper delivery and billing that you need to meet if you want to avoid denied claims (or worse). At Spruce, our specialization in medical communication and care coordination puts us in an ideal position to help practices with many of these CCM criteria, and our platform can do so in a way that makes your life simpler and better instead of more burdensome. Read on to see how!

1. Time Requirements and Documentation

Each CCM code has a time requirement, starting with 99490, which mandates “at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.” CMS also specifically states that “CCM services are typically provided outside of face-to-face patient visits,” so you can count the time you spend on your CCM patients when they’re not in your office, including the time you spend communicating with them directly or with your staff and other colleagues to coordinate care. CMS has additionally assigned “general supervision” status to the CCM codes, so the time and effort of your clinical staff for these patients can also be counted in your billing.3

This is great, except it can be a pain to keep logs of all of your work, not to mention trying to track down what your staff is doing. Do you really want to run a timer and make a new note in your EHR every time you pick up the phone? Instead, you can use Spruce to power your entire communications system, including phones, fax, SMS texting, secure messaging, email, group chat, and telemedicine.

The Spruce system automatically keeps logs of all of your team’s communication, including call times and message timestamps, and we treat it all as part of a secure, persistent medical record. This means that you’ll have a built-in audit trail for your time and the time of your staff, all of which can be important evidence to justify your CCM billing.

I’m an emergency medicine doctor, and I sometimes use Spruce to follow up with patients I’ve seen. I don’t bill them for CCM, of course, but I often think about how easy it would be to do so with Spruce, were I a primary care provider. Check out how our platform handles call records, for instance:

Spruce call and internal note

Each patient on Spruce has a longitudinal thread of all of the communication and notes that involve them, and what you’re seeing in the image above is part of one of those threads. The screenshot starts with a system-generated log of my outbound call to a patient, which lasted 5 minutes and 18 seconds, and afterward, you can see that I left an internal note (visible only to myself and any teammates I might have) with a few quick details on what we talked about. That’s pretty minimal effort for a secure, chronological way of documenting your time and activity.

Messaging on Spruce is also recorded in patient threads, so you can keep track of your care management activities that happen in text form.

Spruce messaging conversation

In the conversation thread above, I was following up with a friend whose son was sick. Everything is stored permanently for easy review, and you can click the three-dot icon to the right of any message to see more detail, including a timestamp that can help you defend any times you report during billing:

Message detail view

2. Comprehensive Electronic Care Plans

CMS requires that you develop a “comprehensive care plan” for each of your CCM patients, and this plan must meet several specific technical criteria:

  • The plan must be stored electronically
  • A copy of the plan must be given to the patient and/or caregiver
  • The plan must be available in a timely and electronic fashion (fax counts) to people both within and outside of your practice who are involved in the patient’s care

The good news? Spruce can help with all of these.

Spruce has native support for care plans, which are specialized secure message attachments that you can customize completely and then send to patients whenever you need to. Here’s how that might look, as stored in a patient thread on Spruce:

Spruce care plan attachment

When you, your staff, or the patient clicks into the care plan, they see a nicely rendered view of all the information that you want them to have. Here’s an example of the patient view of part of a care plan on Spruce:

Spruce care plan

Spruce also supports secure file transfer, so if you’d rather develop your care plans in PDF format, you can do so and then easily attach them in messages to your patients on Spruce. You can also use Spruce to securely send plans to outside providers, as necessary, whether by fax or encrypted file transfer. Like always, we’ll keep a record of everything your team has sent and received over every channel, so you’ll be able to track down the causes behind any suboptimal handoffs.

Spruce fax

3. Continuity of Care and 24/7 Access

One aspect of chronic care management that worries some providers is the CMS requirement that practices provide “24/7 access to physicians or other qualified health care professionals or clinical staff.” Patients who are being billed for CCM must have a way to access their care team and have urgent needs addressed “regardless of the time of day or day of week,” and that can seem like a tough ask for many primary care practices.

With Spruce, however, practices can increase their provider availability without increasing their pain. Spruce is designed to function as a shared communication inbox with user-specific notification settings and schedules, so your whole team can distribute the demands of increased and after-hours access.

Teams on Spruce can give their patients simple points of access, such as one phone number to call or one app to use, and then seamlessly share the work on the backend. Spruce can let your team handle calls in the office during the day and then help you screen them and answer only important ones (in a disguised way) from cell phones at night. Notifications and paging on the platform let you use non-clinical staff to provide first-line assessment and involve clinical providers only when needed. In effect, you can use the platform as a fully customizable answering service, making sure that team members are notified only when absolutely necessary, providing your patients with truly improved access while preventing them from being permanently on call.

CMS also requires that practices promote continuity of care by ensuring that CCM patients can continue to see the same care team provider. Spruce makes this easy by increasing your team’s communication and treatment options, opening up the possibility of telemedicine and other types of care that can occur in places and at times that would otherwise be impossible. These options let providers more readily respond to the needs of their own patients, keeping them from having to rely on covering providers or emergency departments.

Spruce thread with transcription

4. Enhanced Communication Opportunities

Not only does CMS mandate 24/7 availability for chronic care management, the agency also specifically requires that CCM patients be provided with “enhanced opportunities” for communication with their care teams, including “secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.”

Spruce didn’t lobby the government for that specific wording, but we might as well have, because that’s exactly the type of communication that we built our platform to enable and that we strongly believe will be the basis of all exceptional value-based care in the future.

The CMS language for “asynchronous non-face-to-face consultation methods” deserves specific attention in this section, too. That’s really just a bulky phrase for care that takes place over technologies like text messaging, where communication between a patient and provider may be separated by both time and distance. We’ve been providing the tools necessary for this exact type of asynchronous telemedicine for years on Spruce, and it’s one of our deepest areas of investment and expertise.

Specifically, providers on Spruce can practice asynchronously via multiple types of messaging, but we also have support for a more powerful feature, called “Spruce Visits.” Spruce Visits are rigorous, adaptive clinical question sets that providers can use for anything from triage to definitive care provision. These asynchronous visits greatly simplify history taking and physical exam, while also improving other important clinical tasks, such as documentation and protocol adherence. We’ve written a lot about our Spruce Visits before, and we’d love to see more practices use them to deliver high-quality, efficient care.

5. Patient Consent for CCM

CMS requires practices to obtain patient consent before providing and billing for chronic care management services. There are multiple ways to do this, including verbally, but many organizations choose to document written consent as a best practice, and Spruce can easily make this process seamless and pain-free.

The “saved message” feature on Spruce allows teams to develop their preferred CCM consent language one time and then use it in a protocol-based fashion going forward. This ensures that every patient gets the same complete information and has their preference documented appropriately. Check out an example (exact language for demonstration purposes only):

CCM consent saved message

The Spruce interface allows you to easily choose a saved message and sent it to any patient, at any time, simplifying yet another important communication task and helping to keep your practice compliant.

6. Panel Management for Population Health

Your CCM patients will be a distinct population within your larger patient panel, and you’ll need a way to keep track of them and coordinate your outreach efforts. Spruce supports advanced panel management features, such as tagging and bulk messaging, so you can group your CCM patients and easily get in touch with them for their ongoing care issues.

Tags on Spruce are flexible; you can create tags for anything you want and apply them to any segment of patients with just a few clicks. You can also search by tag, which lets you pull up whichever patients you need to at any given time. Here’s how a patient thread in a Spruce inbox looks with a demonstration “ccm” tag:

CCM tag

7. Comprehensive Care Management

CMS requires practitioners who bill for CCM services to provide their patients with “comprehensive care management.” This directive is a key part of the overall chronic care management initiative, and it contains a number of more granular requirements, such as:

  • Systematic assessment of each patient’s medical, functional, and psychosocial needs
  • System-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management of medications

Many of these requirements depend on planned, longitudinal communication with patients, and Spruce is ideally positioned to help practices excel in this. Spruce allows messages to be scheduled, for instance, which lets providers construct follow-up campaigns that run by themselves, automatically checking on medication adherence, preventive service utilization, health status, and any number of other issues.

Scheduled message

Scheduled messages on Spruce can also be used in combination with saved messages, tagging, and bulk messaging, so you can easily reach the right patients, at the right times, with the right messages for their chronic care needs.


The new chronic care management CPT codes give modern practices a unique and powerful way to be compensated for the important care that they provide to the millions of Americans who live with chronic medical conditions. Spruce was built to enable exactly the type of high-quality, efficient care that these codes seek to promote, and we’d be thrilled to help your organization deliver it in a way that both you and your patients will love.

Book a demo with one of our experts today, and we’ll show you exactly how Spruce can help your practice provide and bill for chronic care management.


References:

  1. Lochner, K. A., Goodman, R. A., Posner, S. & Parekh, A. Multiple chronic conditions among Medicare beneficiaries: state-level variations in prevalence, utilization, and cost, 2011. Medicare Medicaid Res. Rev. 3, (2013).
  2. Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. (Centers for Medicare and Medicaid Services, 2012).
  3. Medicare Learning Network. Chronic Care Management Services Fact Sheet. (U.S. Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), 2016).
  4. Bendix, J. Make CCM work for your practice. Medical Economics (2018).

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