Chronic Care

We use cutting-edge technologies, innovative approaches,
and big hearts all to serve you so you can better serve
your patients.


  Quick Implementation
  Comprehensive Care Coordination
  Practice Personalization
  Monthly Check-in Calls
  Medication Review
  Patient Compliance Visibility
  Financial Incentives
  Revenue Cycle Management
  System Auditing
  Concierge-Level Services
  Quality & Quantity
  Patient Satisfaction
  +100’s More!

It Starts with Quality

At RoseText we know that quality care is everything.

Setup is Quick

A week after enrollment, the patient gets his or her first phone call from the Chronic Care Coordinator.
Together, they review the care plan, establish an ongoing call schedule and get the patient set up in the optional patient portal.

For your patient, CCM quickly becomes a consistent part of the health care delivered by your practice.

Comprehensive Care Coordination

Your patients who qualify for CCM are the most at risk for slipping through the cracks. During care coordination RTI takes care of:

• Identifying eligible patients within the practice
• Personalized care plan development for each patient
• Focus on patient experience and empowerment
• Complete patient support
• Concierge-level services
• Patient satisfaction

From start to finish our comprehensive care coordination has every patient covered.

Practice Personalization

We care for your patients like they are our own family. We give your patients personalized care with:

• Care minutes built ethically and with complete documentation
• CCM documented locally into the practice’s system; no third-party data port or data mine
• Focus on quality and quantity.
• Effective patient tracking and care plan continuity, with “call masking” that makes CCM feel like an extension of your practice

This extra personalization allows our nurses to act as a complete extension of your practice.

Monthly Check-in Calls

Consistent contact with your patients provides many benefits of which some include:

• Review of medications
• Discussion of test results
• Exercise and therapy options
• Scheduling regular or unanticipated office visits with the primary provider
• Referrals to specialists, as needed
• Topics the doctor recommends

Patients are also encouraged to raise questions or concerns that may have arisen since their last call or office visit.

The Evolution of CCM

CMS regulation of chronic care management continues to evolve since its introduction in January 2015. These are some of the changes that CCM has already undergone:

January 2016
While they were not permitted to bill for CCM in 2015, Rural Health Clinics will become eligible to bill for CPT code 99490 starting in January 2016. This is an indication of how the population covered by CCM is expanding.

Remote monitoring can count toward the time per month for CCM, but it cannot be the exclusive source of care management. As wearables and other technologies become more popular and affordable, this will be more prevalent.



What Services Are Included in CCM?

CMS specifies that CPT code 99490 may be used to bill for “non-face-to-face time follow-up care outside of the office.” There must be at least 20 minutes per month of non-face-time follow-up care provided to eligible Medicare patients outside of the office each month, including such activities as:

• Discussing the care plan with the patient
• Reviewing medications and therapies
• Charting
• Scheduling phone-based and other non-office encounters
• Reviewing labs and testing with patients
• Scheduling referrals and coordinating all care
• Coordinating documentation from other doctor offices so that you have all the information you need

The average reimbursement for 99490 is $43 per patient per month. If in each month, a patient is both seen at the office and receives non-face-to-face care management, both incidents are billable that month. There are services for which a provider is not allowed to bill during the same calendar month as CCM. These include:
• Transitional care management (CPT 99495 and 99496)
• Home healthcare supervision (HCPCS G0181)
• Hospice care supervision (HCPCS G0182)
• Certain end-stage renal disease (ESRD) services (CPT 90951- 90970)

How Does CCM Benefit Patients?

• As a patient-engagement program, CCM builds “buy-in” with patients. The program and its various services enhance shared decision-making between the physician and patient around their health issues.
• In addition, since monthly phone check ins occur more frequently than the typical schedule of office visits, CCM adds better visibility into patient compliance with the care plan. Because of the frequency, it is possible to identify issues earlier; if adjustments are needed to a patient’s care, the physician and care coordinator can intervene promptly.

How Does CCM Benefit Physicians?

• Financial incentives for enrolling patients in CCM mean that practices are now compensated for time and care that they were previously delivering for free. Depending upon the number of eligible patients enrolled, CCM revenue can be a significant incremental revenue stream for a practice.
• Monthly CCM calls also tend to reduce the number of calls coming into the office from patients each day; such inbound calls related to acute issues to nursing and other staff are not eligible for compensation, while adding up to a significant number of hours per week. Monthly calls by the Chronic Care Coordinators into the patient’s home allow more visibility into the patient’s home environment and its effect on the patient’s health. This helps the physician build more efficient and insightful care plans.
• Finally, CCM facilitates the transition to outcome-based compensation, the standard the CMS wants to apply in the near future. The time is coming when physicians will be reimbursed at a higher rate when they can demonstrate fewer patient hospitalizations, lower cost of care, more positive outcomes and greater patient satisfaction. CCM systems help a provider demonstrate outcomes.

Recent Blogs and Articles
CCM 2020 Changes

CCM 2020 Changes

Centers for Medicare and Medicaid Services (CMS) has recently released the final ruling for this year's Medicare physician fee schedule. These changes include some exciting new regulations and rules for chronic care management.  One change will be new principal...

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