Event Events

Blueprint for Success: Building and Growing Your Home-Based Primary Care Practice

Blueprint for Success:
Building and Growing Your Home-Based Primary Care Practice

Friday, February 7– Saturday, February 8, 2020
Sheraton Crescent Hotel, Phoenix, AZ

Save-the-date to learn strategies for planning and operating a successful and sustainable home-based primary care practice!

Topics covered include personal readiness, managing change, creating a budget, deciding whether to outsource business services, ­­­staffing models, geographic scheduling, documentation and coding, straddling between fee-for-service and value-based environments, a telemedicine-EMR users’ panel, and interactive exercises that put it all together.

This conference is ideal for all providers and operations staff!

More information will be available soon at or

HCCIntel Practice Management Tip of the Month

Chronic Care Management: One Way to Maximize Fee-for-Service Reimbursement

Would you like to maximize your reimbursements by up to $42 dollars per patient per month for the care being provided? Chronic Care Management (CCM) involves much of what you may already be doing to provide high-quality care for your patients: maintaining a comprehensive electronic care plan, managing transitions, and coordinating care with other professionals within and/or outside of your practice. The good news is that with a basic understanding of Chronic Care Management (CCM) documentation and billing, along with an effective workflow process, you can be fairly paid for providing these valuable services!

In 2015, CCM became separately payable by Medicare; however, it is still underutilized by many providers due to concerns about the documentation requirements or simply because providers don’t understand how this could easily become part of their practice’s workflow.

One concern has been that although many Electronic Health Record (EHR)  systems allow providers to turn on a CCM module for time tracking and other features, it is typically an extra expense to the practice. Many providers find that just by enhancing their knowledge of CCM requirements and by implementing some standardized processes, a CCM module isn’t always needed.

Let’s start with the basics of what qualifies a patient for CCM:

  • Two or more chronic conditions, which are expected to last at least 12 months, or until the death of the patient.
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
  • Comprehensive care plan established, implemented, revised, or monitored.

The medically complex and homebound will all qualify for these services, and home-based primary care (HBPC) practices provide extensive care coordination and management services to their patients. It is pretty typical for providers and clinical staff to spend at least 20 minutes per calendar month to manage their patients’ medical and psychosocial needs.  So why not be reimbursed $42.84 (2019 CMS National Payment Amount) per patient per month? Only 20 minutes of combined clinical staff and providers’ time per calendar month is required to bill for CPT 99490 Chronic Care Management.

If your physicians or other qualified health care professionals (Nurse Practitioners, Physicians Assistants, Certified Nurse Midwives, and Clinical Nurse Specialists) are personally spending a complete 30 minutes within a calendar month addressing the medical and care coordination needs of their complex patients, then you can bill CPT 99491 which pays $83.97 (CMS National Payment Rate).

One potential barrier or source of confusion practices may feel limits their ability to provide CCM services to their patients is how to develop the CCM Comprehensive Care Plan that must be created, monitored, implemented, and provided to patient’s and/or caregivers receiving CCM services. Don’t let this stop you; consider if you have a nurse or other clinical staff that could be designated to support CCM and assist the providers in creating these care plans for patients. Below is an example that contains the care plan fields, which meet CMS requirements.

  • Problem List
  • Expected outcome or prognosis
  • Patient Goals of Care
  • Treatment Plan for each Chronic Condition
  • Symptom Management Plan/Education Resources Provided
  • Care Team (Include roles & responsibilities)
  • Medication List (Mark as reviewed/reconciliation last completed date)
  • Community and Social Services Involved in Care (include role and frequency of interventions)
  • Care Plan Review Date

What other elements are required when providing CCM services to your patients?

  • You must obtain and document either verbal or written consent for the patient to receive CCM services, and only one billing practitioner may provide and report CCM services per beneficiary.
  • Structured Recording of Patient Health Information: Practice utilizes certified EHR technology.
  • Access to Care & Care Continuity: Enable 24/7 access to provider team and other clinical staff with a means for after-hours coverage, designated relationship with a member of the care team, and provide enhanced communication opportunities.
  • Comprehensive Care Management: Systematic assessment/monitoring of all medical, functional, and psychosocial needs, medication reconciliation with review of adherence, potential interactions, and self-management, coordinate home and community-based services.
  • Transitional Care Management: Manage transitions as part of CCM.

For further explanation of the requirements in the CCM Comprehensive Care Plan refer to the following HCCI resource, CCM Care Plan Requirements.

Don’t let the list intimidate you! If you are currently providing longitudinal home-based primary care to your patients, chances are, you are already meeting the requirements but just not billing for it.  This means you could be leaving a significant amount of revenue on the table. To put this in perspective, let’s say you billed 300 traditional CCM charges within a six month period. That’s an extra $12,852 in revenue.

In today’s Fee-for-Service model, you must take advantage of all possible billing opportunities to be sustainable and properly reimbursed for the quality, compassionate care your team is already providing.


Event Events

Join HCCI at GSA 2019 Annual Scientific Meeting

GSA 2019

Join the Home Centered Care Institute (HCCI),
the American Academy of Home Care Medicine (AAHCM)
and other global leaders as we present the first-ever
International Workshop on Home Care Medicine

Friday, November 15 | 8:00 a.m. to 11:30 a.m.
Austin Convention Center | Austin, TX

Through the International Workshop on Home Care Medicine, GSA offers the opportunity to learn the latest trends and developments from home care medicine leaders, build strategic partnerships to address challenges, and network with peers.

Panel 1: Service Delivery and Interprofessional Care (1 hour)

  • Aaron Yao, Research Director, Home Centered Care Institute and Professor, Shandong University, Panel Chair
  • Irina Jara Calabuig, Home Care Physician at Alzira´s University Hospital in Valencia, Spain
  • Theresa Soriano, Regional Chief Health Officer at Cityblock Health and President-elect of American Academy of Home Care Medicine, USA
  • Noriko Yamamoto-Mitani, Professor of Medicine at the University of Tokyo School of Medicine, Japan

Panel 2: Technology (Mobile Diagnostics, EMR) in Home Care (30 minutes)

  • Aaron Yao, Research Director, Home Centered Care Institute and Professor, Shandong University, Panel Chair
  • Zia Agha, Chief Medical Officer and Executive Vice President at WestHealth, USA
  • Dai Yumino, Chief Director of Yumino Medical, Japan

Panel 3: Payments and Revenue Models (1 hour)

  • Eric DeJonge, Chief of Geriatrics, Capital Caring and President of American Academy of Home Care Medicine, USA, Panel Chair
  • Laurence Nivet, Director and Matthieu De Stampa, Head of Medical Staff, HAH-Larger Paris University Hospitals (AP-HP), France
  • Tadashi Wada, Clinical professor at Irahara Primary Care Hospital, Japan

Panel 4: Workforce Education and Training (1 hour)

  • Thomas Cornwell, CEO and Founder of Home-Centered Care Institute, USA, Panel Chair
  • Sabrina Akhtar, Physician Lead of the Home-Based Care Program, Toronto Western Family Health Team, Canada
  • Takashi Yamanaka, Chair and Associate Professor of Home Care Medicine, University of Tokyo, Japan


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Event Events

HCCI at the C-TAC National Summit

Lead. Innovate. Inspire.

HCCI is proud to be a Gold Sponsor of the
C-TAC National Summit on Advanced Illness Care
October 9-11, 2019 in Minneapolis, MN

500 disruptors. One room.

You see the impact our healthcare system has on those with advanced illness. From uncoordinated, fragmented care to inadequate support for family caregivers, navigating advanced illness care has become a treacherous task.

Each year, the Summit gathers a diverse set of leaders – including payers, providers, health systems, entrepreneurs, foundations and advocates – to generate solutions that will change the reality of advanced care for millions of Americans.

The networking sessions, focusing on topics from policy and advocacy to building state coalitions, will give you the chance to meet leaders with the passion to drive change on advanced care and the resources to make it happen.

For more information and to register for the C-TAC Summit, visit

Event Events

AAHCM Preconference presented by HCCI

The American Academy of Home Care Medicine (AAHCM) has partnered with Home Centered Care Institute (HCCI), offering a preconference opportunity for a deep dive into areas critical to a successful home-based primary care practice.

House Calls:
Achieving Clinical Excellence and Sustainability

Thursday, October 17, 2019

Loews Chicago O’Hare Hotel
Louvre Ballroom
5300 N. River Road
Rosemont, IL

Clinical Session
9:00 am – 12:00 pm

Practice Management Session
1:00 pm – 4:00 pm

Optional Office Hours
4:00 pm – 5:00 pm

The AAHCM Preconference is designed to help you enhance your medical knowledge, patient care, and interpersonal and communication skills by illustrating the complex care needs of homebound patients with serious illness and their caregivers through case-based discussions, mini-lectures and question-and-answer sessions. Our faculty of national experts will help you to elevate the clinical care you provide to your home-based primary care patients, as well as to enhance your practice’s sustainability in both the current fee-for-service world and the ever-evolving value-based delivery system.

Clinical Session

Topics in the Clinical Session will include: treatment of homebound or home-limited patients with moderate- to late-stage dementia including behavioral disturbances; transitions of care and care coordination; palliative/supportive care and end-of-life care.

Practice Management Session

Topics in the Practice Management Session will include: advanced coding and billing, including HCC scoring; efficiency strategies to enhance practice operations; creating a value proposition to tell your practice’s story to payers, ACOs, and health systems.


To register for the AAHCM Annual Meeting and Preconference presented by HCCI, click or go to
If you have already registered for the AAHCM annual meeting and want to add a preconference session, please contact member services at 847-375-4719 or [email protected]

Registration Fees
One Session/Both Sessions
Physicians $135/$240
Advanced Practice Providers $90/$165
Residents and Fellows $90/$165
Practice Managers and Operations staff $90/$165
Allied Health Professionals $90/$165

Event Events

GAPNA Preconference presented by HCCI

Attending the GAPNA Annual Conference?
Register today for the Preconference presented by

The Gerontological Advanced Practice Nurses Association (GAPNA) has partnered with Home Centered Care Institute (HCCI), offering a preconference opportunity for a deep dive into areas critical to a successful home-based primary care practice.

House Calls:
APNs Navigating Challenges
and Implementing Solutions

Wednesday, October 2, 2019
12 pm – 5 pm

This Preconference practice management workshop is designed to explore the challenges faced and opportunities presented when caring for complex patients in the home. The aim of the session is to expose learners to the successes and failures in NP-driven practices. Time efficiencies, documentation and coding for house calls, valuing your practice, payer/ACO partnerships, and community resources also will be addressed.

To register for the GAPNA Annual Conference and Preconference presented by HCCI,
go to