Connected Care services are provided by healthcare providers and their staff to patients with ongoing medical conditions to supply medical oversight, care management, and support to increase overall health quality, and promote better health outcomes and patient satisfaction. The Centers for Medicare & Medicaid Services (CMS) developed the Connected Care initiative to educate and promote awareness of chronic disease management for healthcare organizations and to explain the benefits of Chronic Care Management, Principal Care Management, and Remote Physiologic Monitoring for patients. Organizations now have the opportunity to deliver connected care services to their patients to prevent adverse health events, decrease hospital admissions, and promote positive patient-provider relationships.

CCM is a care coordination service that reimburses your practice for care management services for patients with two or more chronic diseases, who are at significant risk of death, acute exacerbation or decompensation, or functional decline. CCM is considered an integral part of healthcare for improving outcomes and patient satisfaction. CCM encompasses all non-face-to-face time and activities performed by physicians, other qualified healthcare professionals, and their staff. Practitioners can bill for these services when at least 20 minutes of non-face-to-face clinical staff time has been attributed to patient care management.

CCM services done by the provider (such as physician, nurse practitioner, or physician’s assistant) can be billed in increments of 30 minutes at an increased reimbursement rate.

Complex CCM is management services requiring at least 60 minutes with a substantial revision of the comprehensive care plan for moderate or high complexity medical decision-making. The complex CCM codes are designed for use

in the most fragile patient populations.

RPM (known as Remote Physiologic Monitoring or Remote Patient Monitoring) is a service provided by healthcare providers and their staff utilizing technology to collect physiologic health data from patients. Patients can transmit data remotely, via secure transmission to their healthcare provider in a different location for data analysis and care oversight. These services allow providers to monitor patients outside of the office setting and track vital health data such as blood pressure, blood sugar, heart rate, and weight and develop trends over time to identify early warning signs.

There are currently five RPM codes that cover services for clinical time spent on RPM services, device setup/education for the patient, and device measurements (16 required per 30-day time frame) via a connected, electronic device.

Beginning in 2020, CMS introduced Principal Care Management (PCM) services to provide comprehensive care management for beneficiaries with a single, high-risk condition. CMS indicates that a qualifying condition will typically be expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or places the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline. Although billable by primary care providers, this service type will primarily be provided by specialty providers such as Cardiologists, Pulmonologists, etc.

The PCM codes were revised in 2021 and now include four PCM codes billable for specialty practices. PCM billed by a specialist can be billed in the same month as CCM services billed by a separate general practitioner.

TCM is a service provided by healthcare providers and their staff to manage and coordinate care for patients after certain types of hospital discharges. These services are performed to avoid costly hospital readmissions and other adverse health events. CMS reimburses providers for timely follow-up and care transition management for recently discharged patients.

TCM codes are billable based on the complexity of patient conditions and have different requirements for outreach and follow-up visits depending on whether the patient is moderate or high complexity.

BHI is an additional service provider that can add to care for patients using non-face-to-face interactions to monitor patients for conditions such as substance abuse, life stressors, mental health, and other behavioral factors of co-diagnoses. The patients’ own health team can oversee general BHI-related issues without the need for a psychiatric consultant. CMS states that BHI components include:

BHI Coordinated Care Management (BHI CoCM) is behavioral health with added attention and psychiatric services. The coordination of care between primary and behavioral health professionals can be documented for reimbursement by CMS.