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Care Management and Care Planning Services
00.01.59n

Policy

ELIGIBLE

TRANSITIONAL CARE MANAGEMENT 
Transitional Care Management (TCM) services are covered and eligible for reimbursement consideration by the Company when ALL the following requirements are met:
  • The individual has medical and/or psychosocial problems that require moderate or high complexity medical decision making.
  • Communication with the individual or the individual's caretaker occurs within 2 business days of discharge by either direct (face-to-face) or indirect (telephonic or electronic) means.
    • If the individual is not reached within 2 business days, the provider may still be able to furnish TCM services provided the individual is reached in enough time for a face-to-face visit to occur within the established time frame (see face-to-face requirements below).
    • The provider must document all unsuccessful attempts in reaching the individual, beginning at a minimum of 2 business days postdischarge, until contact is eventually established.
  • The face-to-face visit must occur within either 7 calendar days postdischarge (for an individual whose condition requires high-complexity decision making) or 14 days postdischarge (for an individual whose condition requires moderate complexity decision making).
    • If the face-to-face visit occurs outside this period (e.g., because the member could not be reached in enough time for a face-to-face visit to occur within either 7 or 14 days), then the provider has NOT provided TCM services. In such cases, the provider should report the appropriate Evaluation and Management (E/M) service furnished based on medical necessity if and when the member is eventually reached.
  • Medication reconciliation and management occurs no later than the date of the face-to-face visit.​
ADVANCE CARE PLANNING 
Advance care planning (ACP) services are covered and eligible for reimbursement consideration by the Company when the following requirement is met:
  • ​The individual has a face-to-face or telehealth encounter with a professional provider or other qualified healthcare professional​ to discuss the advance directives.​
    • Telephone audio-only conversations with the family members and/or healthcare surrogates, without the individual's presence, are not considered as ACP services. 

When ACP service is reported more than once in a calendar year, a change in the individual’s health status and/or wishes about end-of-life care must be documented.​


NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The Company covers the following care management and care planning services; however, these services are not eligible for separate reimbursement whether billed alone or in conjunction with other services. Participating professional providers may not bill members for these services. 
  • Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM)
  • Comprehensive Management and Care Coordination for Advanced Illness (CMCCAI)
BILLING REQUIREMENTS

WHEN TO REPORT TCM SERVICES
TCM services should only be reported once per individual within 30 days of discharge from an inpatient hospital, outpatient hospital, or skilled nursing facility stay, and are only eligible to a single professional provider. TCM services should not be reported until all criteria have been met. If the provider furnishes a medically necessary face-to-face service following the 7- or 14-day visit during this 30-day period, the provider should bill the appropriate E/M service.

WHEN NOT TO REPORT TCM SERVICES
  • When the professional provider reports a procedure with an assigned global​ period (e.g., 10 days, 90 days); in this instance, TCM services are included in the postoperative payment for the procedure
  • When the individual is discharged from the hospital to a skilled nursing facility
  • E/M services performed on the day of discharge as part of the discharge management services cannot be considered the TCM face-to-face visit.
WHEN REPORTING ACP SERVICES
Telephone audio-only conversations with the family members and/or healthcare surrogates, without the individual's presence, should not be included in time calculations for ACP services and should not be reported for reimbursement.​ 

REQUIRED DOCUMENTATION

​There is no frequency limitation on ACP services in a calendar year period. When an ACP service is reported more than once, a change in the individual’s health status and/or wishes about end-of-life care should be clearly documented.

The Company may conduct audits for individuals with multiple ACP claims. Documentation would be expected to support the reasonable and necessary use of ACP as evidenced by the following:
  • The content and the medical necessity of the ACP-related discussion
  • Voluntary participation in ACP by the individual, or in the case of absent decision-making capacity, by the family member or surrogate
  • A change in health status or advance care wishes in order to support repetitive provision of ACP services
  • The scenario for the service: face to face, by phone as a telehealth service including audio and/or video communication
  • The time spent solely for provision of ACP services
  • The names of participants involved in the discussion​​
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, Care Management and Care Planning Services are covered under the medical benefits of the Company's products.

Description

Care management and care planning services use a multidisciplinary team approach to assist individuals in managing their medical, mental, or behavioral health conditions more effectively.

ADVANCE CARE PLANNING

Advance care planning (ACP) is the the face-to-face service between a professional provider or other qualified healthcare professional and the patient/individual discussing advance directives, with or without completing relevant legal forms. ACP services are time-based services. No other active management of the individual’s health conditions should be undertaken for the time recorded when ACP service codes are reported. Brief conversations of a few minutes (performed during an Evaluation and Management [E/M] service) related to wishes concerning potential emergent resuscitation do not represent ACP services. ​The face-to-face time is defined as only that time spent face-to-face with the individual with or without the presences of surrogate(s) such as a healthcare agent, designated decision maker, family member, or caregiver​.

​An advance directive is described as a written document that an individual​ uses to appoint a representative and/or to record the individual's wishes as it relates to future medical treatment in the event the individual is incapacitated and unable to make decisions on their own. Types of written advance directives include, but are not limited to:
  • Healthcare proxy
  • Durable power of attorney for healthcare
  • Living will
  • Medical orders for life-sustaining treatment (MOLST)​

CHRONIC CARE MANAGEMENT AND COMPLEX CHRONIC CARE MANAGEMENT 

Chronic care management (CCM) and complex chronic care management (CCCM) refers to care coordination services provided to individuals with two or more chronic conditions expected to last at least 12 months or for the remainder of an individual's life. These chronic conditions place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.

CCM services have the same criteria and components as CCCM services. According to the Centers for Medicare and Medicaid Services (CMS), CCM and CCCM differ in the amount of clinical staff service time directed by a professional provider or other qualified healthcare professional; the involvement and work of the billing professional provider or other qualified healthcare professional; and the extent of care planning performed. The estimated work time for CCCM services is 60 minutes per month, while the work time for CCM services is at least 20 minutes.

In furnishing CCCM services, the professional provider or other qualified healthcare professional and clinical staff develop a holistic care plan that addresses all aspects of the individual's healthcare needs, including all medical conditions, psychosocial needs, and activities of daily living. Whereas the professional provider or other qualified healthcare professional might not singly furnish all the included components of a CCCM care plan, the provider is nonetheless expected to coordinate all of the included components and update the plan as needed to address any changes in an individual's health needs.

A CCCM plan is typically implemented by clinical staff under the direct supervision of the professional provider or other qualified healthcare professional. In implementing the plan, the staff members typically perform many, if not all, of the following tasks:
  • Communicate and engage with the individual, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of the individual's care
  • Communicate with home health agencies and other community services utilized by the individual
  • Collect and document health outcomes data
  • Provide individual and/or family/caretaker education to support self-management, independent living, and activities of daily living
  • Assess and support the individual's treatment regimen adherence and medication management
  • Identify available community and health resources for the individual and facilitate access to care and services needed by the individual and/or family
  • Develop, communicate, and maintain the individual's comprehensive care plan
COMPREHENSIVE MANAGEMENT AND CARE COORDINATION FOR ADVANCED ILLNESS 

Comprehensive management and care coordination for advanced illness (CMCCAI) refers to the management of members with one chronic condition, rather than multiple (two or more) chronic conditions.

CMCCAI includes the following services for members with ONE chronic condition:
  • Assess for the presence of symptoms on at least a monthly basis
  • Develop a treatment plan to manage symptoms
  • Educate about cause and management of symptoms
  • Assess for psychosocial and spiritual distress and refer for support
  • Provide information regarding prognosis consistent with the individual's preferences
  • Establish goals of care that are consistent with the individual's values and preferences
  • Maintain an ACP that is consistent with the individual's goals and preferences
  • Coordinate care with other healthcare providers and across sites of care
  • Educate the individual and caregivers about role of specialist palliative care and hospice
  • Assess need for specialist palliative care and hospice
  • Coordinate referral to hospice when appropriate
  • Educate and support caregivers providing care to the individual​
TRANSITIONAL CARE MANAGEMENT 

Transitional care management (TCM) refers to care coordination services provided to an individual whose medical and/or psychosocial condition(s) require moderate- or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the individual's community setting (home, domicile, rest home, or assisted living).

References

Centers for Medicare & Medicaid Services (CMS). Frequently Asked Questions about Billing the Physician Fee Schedule for Advance Care Planning Services. July 2016. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched/downloads/faq-advance-care-planning.pdf​  Accessed July 20, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. Advance Care Planning. October 2020. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf. Accessed July 30, 2022.

Centers for Medicare & Medicaid Services (CMS). MLN Fact Sheet. Chronic Care Management Services. December 2019. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf​ Accessed July 30, 2022.

Centers for Medicare &  Medicaid Services (CMS). MLN Fact Sheet. Transitional Care Management Services. July 2021. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed July 30, 2022.
​​
Centers for Medicare & Medicaid Services (CMS). MLN Matters®​ Number MM10000. Billing for Advance Care Planning. May 2017. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10000.pdf​. Accessed July 30, 2022.

Novitas Solutions. Provider specialty: Care management services. [Novitas Web site]. Revised: 07/07/2022. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00170702​. Accessed July 30, 2022.

Coding

CPT Procedure Code Number(s)
ELIGIBLE
99495, 99496, 99497, 99498

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
99424, 99425, 99426, 99427, 99437, 99439, 99487, 99489, 99490, 99491 

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

G0019Communit​y health integration services performed by certified or trained auxiliary personnel, including a comm​unity health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month, in the following activities to address social determinants of health (sdoh) need(s) that are significantly limiting the ability to diagnose or treat problem(s) addressed in an initiating visit: person-centered assessment, performed to better understand the individualized context of the intersection between the doh need(s) and the problem(s) addressed in the initiating visit. 
G0022Community health integration services, each additional 30 minutes per calendar month (list separately in addition to g0019)
G0023Principal illness navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator; 60 minutes per calendar month, in the following activities:  person-centered assessment, performed to better understand the individual context of the serious, high-risk condition. 
G0024Principal illness navigation services, additional 30 minutes per calendar month (list separately in addition to g0023)
G0136Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes
G0140Principal illness navigation - peer support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month, in the following activities:  person-centered interview, performed to better understand the individual context of the serious, high-risk condition. 
G0146Principal illness navigation - peer support, additional 30 minutes per calendar month (list separately in addition to g0140)
G0506Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)
​G0511Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month
G0512Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month​​
S0257Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate (list separately in addition to code for appropriate evaluation and management service)
S0311Comprehensive management and care coordination for advanced illness, per calendar month​​


Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

1/2/2024
1/16/2024
00.01.59
Claim Payment Policy Bulletin
Commercial
No