CCM

What We Do

ClarityCCM^TM employs the AHRQ’s Patient-Centered Team-Based Care* model in partnering with you and your practice to help provide the full range of chronic care and preventive care services. Although each individual service is beneficial by itself, it is our firmly held belief that the combined delivery provides the most efficient and beneficial approach, for providers and patients.

CCM

Chronic Care Management (CCM)

Non-face-to-face, time-based encounters, performed monthly by remote ancillary staff under provider’s general supervision, outside of and between regular office visits. Designed to educate and improve coordination of care for those with two or more chronic conditions, which comprises > 80% of the Medicare population in a typical practice. Medicare has made enrollment simple and has expanded the number of available CPT/HCPCS codes.

RPM

Remote Physiologic Monitoring (RPM).

Using FDA-approved remote devices, RPM allows the provider to better track a patient with certain chronic conditions using objective data, with only one chronic condition required to implement. Medicare has recently expanded and simplified the CPT/HCPCS codes available, with several monthly time-based codes provided remotely under general supervision, that can be delivered in addition to CCM.

AWV

Annual Wellness Visit (AWV)

Not to be confused with an “annual physical” (for which a CPT code does not exist), AWV includes a Health Risk Assessment (HRA) and a comprehensive medical and health status evaluation. This creates (initial AWV) or updates (subsequent AWV) a personalized 5-year preventive plan of care. With most of the information being self-generated electronically and remotely by the patient, and the required office-based data largely collected by ancillary staff, AWV requires minimal time spent by the provider. For Medicare beneficiaries within their first year of enrollment, a one-time Initial Preventive Physical Exam (IPPE) is performed instead.

ACP

Advance Care Planning (ACP)

Face-to-face service between the provider/staff and the patient/family. It’s designed to discuss advance directives, including durable power of attorney for healthcare, living will, instructional directive, and personal values history, and can include help in the completion of relevant legal documents. There is no patient co-pay if done in conjunction with the AWV. A time-based code, a portion can be performed by ancillary staff under direct supervision, and be done several times per year if patient status changes.

Other

Other Services

We also assist with other important services such as Transitional Care Management (TCM), Behavioral Health Integration (BHI), Alcohol Misuse Screening, Depression Screening, and Diabetes Self-management Training (DSMT).

Who We Serve

Independent & ACO Member Practices

Instant additional revenue streams for your current patients, while also creating alignment and shared savings with Medicare’s Accountable Care Organizations (ACOs), Merit-Based Incentive Program (MIPS), and other risk-sharing agreements.

Hospital or Corporate-Owned Practices

In many cases, even higher revenue potential for all services provided based on additional facility fee.

Multi-Specialty Groups

Opportunities exist for medical specialists, not just PCPs.

Accountable Care Organizations

Alignment with all Medicare Shared-Savings Programs (MSSPs) via enhanced care coordination, patient experience, and chronic & preventive care services.

Rural Health Centers/Critical Access Hospitals

Similar rules apply, albeit with some distinct differences regarding compliance issues.

White Papers

Some providers are understandably troubled by the recently released CMS Physician Fee Schedule Final Rule. After all, the final conversion factor has settled at $32.41, a decrease of ≅ 10% from the...

Previously, we’ve discussed the numerous benefits of incorporating Chronic Care Management (CCM) into a primary care practice. Intended to help care for the sickest and most challenging Medicare patients, those with two...

Now that we appreciate the numerous benefits of starting a CCM program, both from the standpoint of patient care and reimbursement, as well as realizing some of the reasons behind the hesitation...