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Value-Based Care Solutions Glossary

This value-based care solutions glossary will give you any definitions you need to know about Chronic Care Management, Annual Wellness Visits, Quality Improvement programs, Behavioral Health Integration, and more.

Chronic Care Management (CCM)

Chronic Care Management includes the oversight and educational activities conducted by health care professionals to help Medicare patients with chronic conditions such as diabetes, high blood pressure, high cholesterol, and hypothyroidism. CCM helps patients understand their conditions and how to live successfully with them. Care coordinators help patients create care plans and care goals to achieve ongoing quality of life.

On January 1, 2015, the Centers for Medicare and Medicaid Services (CMS) implemented a new reimbursement program for providers administering Chronic Care Management (CCM) services. The program is designed to reimburse practices every month for each patient enrolled in a Chronic Care Management program. Ultimately, the goal is to increase access to care for chronically ill patients, improve patient outcomes, and help lower the financial strain on the healthcare system.

CCM Patient Eligibility

• Two or more chronic conditions expected to last at least 12 months and that place the patient at significant risk of decline
• A qualifying office visit within the previous 365 days
• Only one provider billing for CCM services
• Verbal or written consent from the patient

CCM Service Elements

• Minimum of 20 minutes per month of non-face-to-face care
• 24/7 access to qualified healthcare professionals
• Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other non-face-to-face consultation methods (for example, email or secure electronic patient portal)

CCM Care Plans

• A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements
  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of the individuals responsible for each intervention
  • Medication reviews
  • Community/social services ordered
  • A description of how the services of agencies and specialists outside the practice will be directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan

Non-Face-to-Face Chronic Care Management

Care coordinators should use telephone, text, email and other non-face-to-face means to contact and monitor patients regularly. They should also deliver patient education and counseling, give appointment reminders, and facilitate peer support and resource referrals for coping with illness.

Chronic Care Management Software/Platform

Software used to manage the care of chronically ill patients.

Care Coordinator

Medicare patients with two or more chronic conditions are offered twenty minutes of care monthly through care coordinators. Care coordinators collaborate with the patient and their provider to create a comprehensive, individualized care plan around the patient's needs. Care coordinators also follow up on patients’ care goals, provide educational materials and Social Determinant of Health resources, and help with appointment scheduling and medication refills. 

CCM Billing Codes

CCM uses six primary codes to report services:

• 99490: non-complex CCM is a 20-minute timed service provided by clinical staff to coordinate care across providers and support patient accountability.
• 99439: each additional 20 minutes of clinical staff time spent providing non-complex CCM directed by a physician or other qualified health care professional (billed in conjunction with CPT code 99490).
• 99491: CCM services provided personally by a physician or other qualified health care professional for 30 minutes.
• 99487: 60 minutes of complex CCM which includes some medical decision making.
• 99489: add on code for an additional 30 minutes of complex CCM billed in conjunction with 99487.
• G0511: HCPCS code for CCM used by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

MIPS (Merit-based Incentive Payment System)

MIPS, or the Merit-based Incentive Payment System, is part of Medicare’s Quality Payment Program. MIPS rewards eligible Medicare providers for improving the quality of their care and their patient outcomes.

Four Components of MIPS

• Quality (formerly known as Physician Quality Reporting System (PQRS))
• Cost (formerly known as Value-Based Payment Modifier (VM))
• Promoting Interoperability (formerly known as Medicare EHR Incentive Program for eligible professionals)
• Improvement Activities

Goals of MIPS

• Move Medicare Part B clinicians to a value-based payment system
• Provide clinicians with flexibility to choose the activities and measures that are most meaningful to their practice
• Create reporting standards that align with Advanced Alternative Payment Models (APMs) wherever possible

Medicare Shared Savings Program

The Medicare Shared Savings Program is one program that providers, hospitals, or health systems can join to create an Accountable Care Organization (ACO). MSSP is different from many other ACOs because providers’ performance is only based on the quality, costs, and care of Medicare fee-for-service beneficiaries. Providers who contribute to the ACO’s savings receive a share of those savings. 

ACO (Accountable Care Organization) 

ACOs are formed by providers, hospitals, and health systems who band together to practice value-based care. Each ACO is responsible for the quality, cost, and patient experience of an assigned patient population. If the ACO performs well, its members can benefit from the revenue that ACO generates.

CMS (Centers for Medicare and Medicaid Services)

The Centers for Medicare & Medicaid Services (CMS) is part of the U.S. Department of Health and Human Services. CMS oversees Medicare, including Medicare fee-for-service payments, MIPS, MSSP, and other ACOs focused on Medicare patients.

CMS Innovation Center 

An area within CMS committed to testing innovative payment techniques and service delivery models to improve quality of care. They are responsible for CMS’s ACO programs.

Annual Wellness Visit (AWV)

The AWV is an ongoing yearly benefit available to Medicare beneficiaries after 12 months of enrollment in Part B Medicare coverage. During the AWV, the patient fills out a Health Risk Assessment (HRA) that includes questions about their health history and risk factors. The patient’s provider uses information from the HRA to develop a long-term preventative care plan for the patient.

Behavioral Health Integration (BHI)

Behavioral Health Integration is a Medicare program designed to integrate mental health treatment with physical health treatment. Through BHI, qualifying patients can receive a detailed care plan and communication from behavioral health coordinators every month to help them stay on track with their behavioral health. 

FQHC (Federally Qualified Health Center)

A Federally Qualified Health Center is a reimbursement designation from the Bureau of Primary Health Care and the Centers for Medicare and Medicaid Services. FQHCs are community-based organizations that provide comprehensive primary care and preventative care for patients who might otherwise have trouble accessing it. FQHCs often receive different reimbursement rates than traditional clinics for programs like CCM, AWVs, and BHI. 

RHC (Rural Health Clinic)

A Rural Health Clinic (RHC) provides primary care services to patients in rural and medically underserved areas. The Centers for Medicare and Medicaid Services (CMS) designates RHCs and reimburses them at different rates than traditional clinics. Like FQHCs, RHCs often benefit from higher reimbursement rates for CCM, AWVs, and BHI.

CAH (Critical Access Hospital) 

A Critical Access Hospital is a designation given to eligible rural hospitals by CMS. These hospitals receive certain benefits, such as cost-based reimbursement for Medicare services. Some RHCs and CAHs are closely affiliated, since they serve a similar patient population. 

SDOH (Social Determinants of Health)

Social Determinants of Health are the non-medical factors that impact patients’ health outcomes, like economic stability, education access, healthcare quality, neighborhood and environment, and community support. Value-based care programs encourage providers to take Social Determinants of Health into account when treating patients. 

Want to Learn More?

If you would like to learn more about value-based care and why it’s beneficial to patients, visit our article on 5 Strategies to Improve the Quality of Healthcare.