Innovation Pulse: Meet the new CMS code worth $17 billion annually

“If this was just another new code, it would be a yawn ... It was a double bang."
By Tom Sullivan
09:41 AM

Travis Bond spoke plainly but with a sparkle in his eye when he confessed: “We just got lucky.”

Bond, CEO of personal health record company CareSync, was referring to CPT code 99490 – something of a sleeping giant in the Centers for Medicare and Medicaid Services 2015 Physician Fee Schedule that has the potential to be rather lucrative for providers and the IT innovators who serve them.

The meaningful use program incentivized hospitals to adopt electronic health records and the $30 billion CMS has thus far disbursed, in turn, has lured a rush of vendors to innovate with electronic health records software (albeit arguably within certain detrimental confines). And the new code carries a strikingly similar potential, as many health systems will have to invest in platforms that enable them to care for patients in accordance with 99490.

“Every physician group serving a Medicare population will be interested in participating,” said Jerry Shultz, president of population health management vendor Lightbeam Health Solutions.

And the grand total CMS will pay out for 99490 promises to rapidly surpass EHR reimbursement funding.

The new Meaningful Use
“Beginning January 1, 2015,” CMS explained in an MLN Matters document, “Medicare pays separately under the Medicare PFS American Medical Association Current Procedural Terminology code 99490, for non-face-to-face care coordination services furnished to Medicare beneficiaries with multiple chronic conditions.”

CMS requires that clinical staff spend at least 20 minutes per month with patients that have two or more chronic conditions expected to last 12 months or longer, those chronic conditions “place the patient at significant risk of death, acute exacerbation, decompensation or functional decline,” and providers must establish a comprehensive care plan that is implemented, monitored and revised. 

[Read more Innovation Pulse columns]

Bond, a serial entrepreneur, did the math: With 36 million Medicare patients having multiple chronic conditions at a rate of approximately $40 dollars per month, throughout the course of a year that totals approximately $17.25 billion dollars. 

Every year.

“If this was just another new code, it would be a yawn,” Bond said. “The big deal is that this is now a code that can be subcontracted out, so it was a double bang: CMS will give providers money to manage patients between visits in post-acute care settings, and the second was it can be subcontracted.”

Something of a surprise
CMS announced 99490 only about four months before the CPT code went live, so payers, providers, technology vendors, and even agile innovators had very little time to adapt.

Doing so is a significant undertaking, too, because payment for CCM services under code 99490 requires that providers record patient demographics, medications, allergies via a certified EHR to build a structural clinical summary, create a patient-centered care plan, provide patients with a written or electronic copy of the care plan, ensure that the plan is available electronically to anyone within the practice, and share it with other providers but not via fax. 

“Meaningful use Stage 3 will put patients in a more prominent position than stage 2,” said Bond. “And this code will give healthcare organizations at least reimbursement to make investments into technology that really include the patient as a meaningful component of the healthcare equation.”

Yes, this is where CareSync comes in. The company offers what it calls patient-centered care coordination to some 20,000 people and, according to Bond, has collected records from more than 10,000 providers to date.

Mad dash
With a potential $17 billion on the line CareSync is not the only innovator making big plans. IT consultancy IDC, in fact, counts population health vendors including CircleLink Health, Kryptiq, MD Revolution, and SmartLink as ready to support CCM – though each is taking a slightly different tack.

And once they get wise to the opportunity, Bond expects everyone from apps and EHR makers to call centers in India to start looking to cash in.

Indeed, among the many physician-turned-entrepreneurs, emerging care coordination platform vendors, hospital CIOs and various innovators I queried about 99490, the consensus is that it could become a game-changer. But that requires some technological heavy-lifting far from ubiquitous in the industry.

“If you can automate the process of identifying qualified candidates –  those with 2 or more chronic conditions – automate notifying those candidates that they get to participate in this program at no charge, and then have a workflow engine the care management team can leverage to ensure proper follow up then you will be able to truly seize this opportunity,” Lightbeam’s Shultz said. “The additional revenue from this program will fund the infrastructure needed to manage this initiative and will translate to managing other value-based contracts.”

Looking beyond just the innovators likely to rush toward the new CPT code, Bond also predicted that in 2016 commercial payers will mimic CMS and play nice with 99490 if only because they realistically have to.

At that point “you can pretty much triple the $17 billion,” Bond explained, because all Americans with two or more chronic conditions will become eligible. 

Twitter: SullyHIT
Email the writer:

Like Healthcare IT News on Facebook and LinkedIn

Want to get more stories like this one? Get daily news updates from Healthcare IT News.
Your subscription has been saved.
Something went wrong. Please try again.