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Population Health Initiative: Examining the Revenue Lines Print E-mail
Written by Mario Espino   
Wednesday, 23 August 2017 17:53

In part I of this series, we took a high-altitude look at a population health initiative. Today we will examine two core revenue lines essential for a successful initiative. These revenue lines are generated from Medicare-allowables but are transferable to other payer models as they all mostly follow traditional Medicare.

Transitional Care Management (TCM), not to be confused with Transformational Care, is the first one to embrace. Properly implemented TCM provides the practitioner the best chance to get started, not only gathering data, but getting those patients recently discharged from an inpatient acute care setting back in front of their primary care physicians (PCPs). This is crucial as we find that many PCPs are not aware of the inpatient stay and the event that caused the admission, let alone the changes and/or additions made to the patient's care plan and medications.

TCM is a fundamental opportunity to coordinate medical treatment plans for better management of the patient’s condition(s). This is done in either a less than 7 day (CPT Code 99496) or a less than 14 day (CPT Code 99495) window, from the date of discharge, for the patient to be seen by the primary care physician after discharge, as a face-to-face encounter. Revenue ranges from $130 to $200 per patient.

Chronic Care Management (CCM) is the second leg of the core data-gathering process that enables a comprehensive population health initiative. This allows for the collection, aggregation, and management of data from across the continuum and converts the same into one care plan that is actionable and can be supervised by the PCP. This is critical because we know that coordination of care provides better outcomes and saves money. But before CCM, there was no incentive to manage and collect patient information from other continuum providers while collaborating with patient and PCP to look for gaps or improvements in care.

The chronic care management market is big and growing. 36 million Medicare patients suffered from two or more chronic conditions in 2016. That number is expected to jump to 80 million by 2030. 

CCM started later than TCM, and it is a non-face-to-face, per month, per patient amount of monies to manage the care for those that meet the CMS chronic care management definition. There were key improvements for 2017: Increased payment and additional codes. The single CCM code in 2016 paid approximately $42. Now there are 3 codes and payment can range from approximately $43 to over $141, depending on how complex a patient’s needs are. There are requirements by CMS that will have to be in place to bill; but the benefits outweigh the requirements.

There are more revenue lines but these should be at the core of a successful population health initiative.

Resources for TCM and CCM

CMS: TCM Services Fact Sheet

Healthcare IT News: Chronic Care Management: $50 Billion Market

WSJ: Moving Away from Fee-for-Service

CMS: Chronic Care Management Services Changes

CMS: MLN Chronic Care Management

About the author:
Mario Espino is the Chief Population Health Officer for Accountable Care Options of Florida, in Boynton Beach. Mr. Espino is the founder of MGM Medical Group as well as a Blogger/Writer for

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