CARE MANAGEMENT SERVICES

Transcription

1 CARE MANAGEMENT SERVICES 1

2 CARE MANAGEMENT SERVICES: Defined Management and support services provided by clinical staff under the direction of a physician or other qualified health care professional To a patient residing at home or in a domiciliary, rest home or assisted living facility 2

3 Services may include: Establishing, implementing, revising or monitoring the care plan Coordinating the care of other professionals and agencies Educating the patient or caregiver about the patient s condition, care plan and prognosis 3

4 Role of Physician or Other Qualified Health Care Provider Oversees the management and/or coordination of services, as needed, for: all medical conditions, psychosocial needs and activities of daily living 4

5 Plan of Care Must be documented and shared with patient and/or caregiver Based on physical mental, cognitive, social, functional and environmental assessment Is a comprehensive plan of care for all health problems 5

6 Plan of Care Includes: Problem list Expected outcome and prognosis Measurable treatment goals Symptom management Planned interventions Medication management Community/social services ordered How services of agencies/specialists unconnected to the practice will be directed/coordinated Identification of the individuals responsible for each intervention Requirements for periodic review Revision of the care plan, when applicable 6

7 Requirements May be reported only once per calendar month May be reported by only the single physician or QHP who assumes the care management role for the calendar month 7

8 Time Requirements Face-to-face AND non-face-to-face time spent by clinical staff: Communicating with patient/caregiver, other professionals, agencies Revising, documenting and implementing care plan Teaching self-management Only count the time of one clinical staff member when two or more clinical staff members are meeting with the patient Do not count clinical staff time on day when physician or QHP reports an E/M service 8

9 Typical activities Communication and engagement regarding aspects of care Communication with home health agencies and other community services Collection of health outcomes data and registry documentation Patient/family/caregiver education Assessment and support for treatment regimen adherence and med management Identification of available community and health resources Facilitating access to care and services needed by patient/family Management of care transitions not reported as part of TCM Ongoing review of patient status, including labs and other studies Development, communication and maintenance of comprehensive care plan

10 Office/Practice Capabilities 24/7 access to physicians/qhp Continuity of care Timely access and management for f/u after ED visit or D/C Utilize EHR so care providers have timely access to clinical info Use standardized method to ID patients who require services Have internal care management process/function Use form/format in the medical record that is standardized in the practice Able to engage/educate patients/caregivers, coordinate care

11 99490 Chronic Care Management Services At least 20 minutes of clinical staff time directed by physician or QHP per calendar month with the following required elements: Multiple (>2)chronic conditions expected to last at least 12 months or until death Chronic conditions risk death, exacerbation/decompensation or functional decline Comprehensive care plan established, implemented, revised, monitored 11

12 Comparison of Care Management Codes 12

13 Billing Requirements from CMS Inform beneficiary about availability of CCM Obtain written agreement to have services provided Document in record that CCM explained and note decision to accept or decline Provide written or electronic copy of care plan Inform beneficiary of right to stop CCM at any time Inform beneficiary that only one practitioner can furnish and be paid during a calendar month 13

14 CMS Requirements Prior to Service Explain to beneficiaries cost-sharing obligation involved (CMS has no statutory authority to waive applicable coinsurance) Obtain consent prior to furnishing the service Enhanced opportunities for communication through asynchronous non-face-to-face consultation methods EHR: Must be certified EHR technology (CEHRT) 14

15 Where can I find the final rule? 2015 CPT Professional Edition Final rule: pp