Which Care Management Programs Can Providers Combine?

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has established several care management programs to improve outcomes and reduce costs for beneficiaries with chronic conditions and higher complexity. These include:

• Behavioral Health Integration (BHI)
• Chronic Care Management (CCM)
• Principal Care Management (PCM)
• Remote Patient Monitoring (RPM)
• Transitional Care Management (TCM)

These programs enable provider organizations to enhance patient value and outcomes and improve fee-for-service revenue. Additionally, programs can be used in tandem to harness complementary features and maximize patients’ physical and mental health.

It is common for providers to feel uncertain about how to manage programs that are implemented concurrently or synchronously.

Figure 1 provides an overview of our findings in a review of CMS FAQs and Fact Sheets. 

Figure 1: Overview of which care management programs can be combined.

As CMS intended, many programs are designed to be used together, while some combinations have specific rules for how they can be used together.

Which programs can be combined with Chronic Care Management and Principal Care Management?

Chronic Care Management (CCM) focuses on patients with more than one chronic condition expected to last at least 12 months. Principal Care Management (PCM) focuses on patients with one chronic condition. 

Both of these programs typically comprise the core of services offered through CMS’s care management physician fee schedule and are frequently the first programs that most provider organizations implement.

Because of this, both programs work well with the other care management programs. There are two exceptions to highlight.

Don’t bill complex and non-complex CCM in the same month

First, the two Chronic Care Management types, non-complex and complex, cannot be billed in the same month. 

A single provider cannot bill PCM and CCM concurrently 

CCM and PCM can be billed concurrently; however, not by the same provider. Therefore, CCM and PCM cannot be billed by the same practitioner for the same patient in the same month. Still, it is permissible when two different providers deliver each program independently. 

For example, a primary care physician could offer Chronic Care Management, and a specialist, like an endocrinologist or cardiologist, could offer Principal Care Management. In this scenario, the conditions managed through CCM and PCM programs must differ. 

The primary care physician may focus their CCM program on a patient’s diabetes and obesity, and a cardiologist may concentrate on the patient’s congestive heart failure.

Which programs can be combined with Transitional Care Management?

Transitional Care Management (TCM) focuses on preventing hospital readmission by providing 30 days of interactive contact, non-face-to-face care coordination, and in-office services. 

There are a couple of nuanced requirements to keep in mind.

CCM and TCM billable days cannot overlap in a calendar month

The most common combination with TCM pairs it with CCM. The two programs can work well together to provide a continuum of care. However, CCM and TCM days of service cannot overlap in one month. 

CCM service codes can be billed during the same calendar month, but only if the TCM service period ends before the end of the qualifying month. Naturally, this combination must be medically reasonable and necessary, and providers must meet all other CCM billing requirements during the remainder of the month. 

Some non-care management services cannot be combined with TCM

Medicare does not allow the TCM service codes to be billed during the same service period as several non-care management programs, including:

• Home health care supervision covered under HCPCS G0181
• Hospice care supervision covered under HCPCS G0182
• ESRD services covered under CPT 90951 through 90970 
• During a post-operative global surgery period

Which programs can be combined with Behavioral Health Integration?

Behavioral Health Integration (BHI) strives to provide patients with better primary care access to treatment for mental health, substance abuse conditions, common life stressors, stress-related physical symptoms, and general health behaviors.

This monthly service includes core service elements like assessment and monitoring. 

BHI and CCM are complementary programs

CMS views Chronic Care Management and Behavioral Health Integration as distinct services with some overlap. They each address different but possibly related conditions. 

While CCM provides care planning for all health issues, including preventive services, BHI focuses on individuals with behavioral health issues. BHI uses validated rating scales for assessment and does not support preventive services. Also, where CCM requires using certified electronic health information technology, BHI does not. 

BHI can be billed for the same patient in the same month as CCM if the patient provides advance consent for both services. Additionally, all requirements for each program must be met independently. 

Which programs can be combined with Remote Patient Monitoring?

Remote Patient Monitoring (RPM) offers the most flexibility to complement other care management programs, including CCM, TCM, BHI, and PCM. Because CMS permits concurrent billing with RPM, providers have maximum flexibility when selecting the right combination of care management services for patients.

Determine the right care management program combinations for your patients and practice

CCM + TCM: This combination makes sense if a Medicare patient cohort has periodic or frequent inpatient admissions. This combination provides the best continuity of care.

RPM added to any program: This is appropriate when the condition under management aligns well with the types of RPM devices and symptoms you want to monitor closely. These typically include congestive heart failure, hypertension, diabetes, and COPD.

BHI + CCM or PCM: This combination helps patients with both physical and behavioral issues. Both types of conditions can benefit from being addressed with a holistic approach.

Manage concurrent care management programs with ThoroughCare 

ThoroughCare offers a comprehensive software platform to streamline care management across all program types. Our tools automatically account for all of Medicare’s rules and requirements while documenting service records for each program. 

Plus, ThoroughCare makes it easy to engage patients and maximize service time. To get started, simply enroll patients in any new care management program.