CHRONIC CARE MANAGEMENT - hthu.net · Chronic Care Management THE GATEWAY TO QUALITY CARE OVERVIEW Chronic Care Management (CCM) ... Any patient not attributed to the CPCI model can

CHRONIC CAREMANAGEMENT

The Gateway to Quality Care

ICAHN – IRCCO CCM MANUAL 2017 1

Chronic Care Management

THE GATEWAY TO QUALITY CARE

OVERVIEW

Chronic Care Management (CCM) services are designed for patients with two or more chronic conditions, whose quality of health will benefit from coordinated patient centered care. The primary goal for CCM is to reduce the effects of acute and chronic illness exacerbations, that directly impact patient outcomes. This is achieved by involving the patient in their own care, building collaboration between healthcare providers, and improving communication across all service lines and care transitions. By meeting clinical, social, and environmental needs, CCM can improve a patient’s quality of life.

MISSION

ICAHN is a not-for-profit 501(c)3 corporation, established in 2003 for the purposes of sharing resources and education, promoting efficiency and best practice, and improving healthcare services for member critical access hospitals and their rural communities. ICAHN , with 55 member hospitals, is an independent network governed by a nine-member board of directors.

ICAHN's mission is to strengthen Illinois critical access hospitals through collaboration. ICAHN accomplishes this by ensuring appropriate funding and financial resources, continuing efforts to be a recognized resource for Illinois' CAHs, promoting efficient use of information technology, offering ongoing educational opportunities, and developing and offering projects which add value to the organization and its members.

ICAHN also works to provide these same methodologies at varied levels to organizations that fall outside their current Illinois collaborations and ACO. ICAHN strives to provide services that will ultimately help healthcare providers achieve process improvement, utilize available resources, and improve overall patient-centered care.

Copyright © 2017 by Lesa Schlatman RN, BSN. All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher: ICAHN, Princeton IL. 61356.


Table of Contents

List of Abbreviations:..................................................................................................... 4

CHAPTER 1 WHO CAN PARTICIPATE? ....................................................... 5

1.1 Use of a CMS Certified Electronic Health Record (EHR) .................................. 6

1.2 Ability to Build a Comprehensive Care Plan ..................................................... 7

1.3 Ability to Provide CCM Patients with 24/7 Access to Care ............................. 8

1.4 Provide Patients Access to Successive Routine Appointments .................... 10

1.5 Process for Transitions in Care ......................................................................... 11

1.6 Provide Patient with Enhanced Communication Possibilities ...................... 12

1.7 Provide Each CCM Patient 20 Minutes Non-Face-to-Face Time ................... 13

1.8 “General Supervision” to Care Team Members .............................................. 13

CHAPTER 2 HOW TO GET STARTED ......................................................... 14

2.1 Assemble a Care Team ....................................................................................... 14

2.2 Patient Eligibility ................................................................................................ 16

2.3 High Risk Patients .............................................................................................. 18

2.4 How Many Patients Can Staff Handle? ............................................................ 20

CHAPTER 3 ASSIGN PROVIDERS/CARE TEAM MEMBERS ..................... 22

CHAPTER 4 PATIENT CONSENT ............................................................... 24

4.1 What Must Be Discussed with the Patient? ..................................................... 24

4.2 A Brand New Patient ......................................................................................... 28

4.3 An Established Patient Not Seen in Last 12 months ...................................... 29

4.4 An Established Patient Seen in Last 12 Months.............................................. 30

4.5 The Patient is Incompetent to Sign Own Consent ......................................... 31

4.6 Documentation of Consent ............................................................................... 32

4.7 When is New Consent Required? ..................................................................... 33

CHAPTER 5 ORGANIZING INFORMATION AND TOOLS ........................ 40

CHAPTER 6 INITIATING CCM SERVICES .................................................. 44


6.1 Preparations Before Calls .................................................................................. 44

6.2 Scheduling Appointments / Contact by Phone .............................................. 46

CHAPTER 7 WHAT HAPPENS AFTER PATIENT CONSENT? .................... 49

7.1 Step 1: Review and Set Up Enrollment ............................................................ 49

7.2 Step 2: Begin Care Plan ..................................................................................... 51

7.3 Step 3: Review EHR Components (Mandatory) .............................................. 65

7.4 Step 4: Set Up Calendar ..................................................................................... 65

7.5 Step 5: Finish Setup............................................................................................ 66

7.6 Step 6: Complete Care Plan ............................................................................... 67

7.7 Step 7: Final Review ........................................................................................... 68

CHAPTER 8 TIME TO BEGIN CCM SERVICES ............................................ 69

8.1 What Activities Can Be Counted in Those 20 Minutes? ................................. 69

8.2 CCM Services Per Calendar Month ................................................................... 73

8.3 How to Motivate Your Patient ......................................................................... 74

8.4 Reaching Out to Each Patient ........................................................................... 77

8.5 Transitions in Care ............................................................................................. 83

CHAPTER 9 BILLING PARAMETERS .......................................................... 86

9.1 Communication Process .................................................................................... 86

9.2 When Is It NOT Okay to Bill for CCM? ............................................................. 87

9.3 What Form Should Billing Use? ........................................................................ 89

9.4 What Codes Can Be Used? ................................................................................. 89

9.5 Other Miscellaneous Codes ............................................................................. 100

9.6 Submitting the Claim ....................................................................................... 100

CHAPTER 10 INFORMATION AND RESOURCES .................................... 103

Bibliography ............................................................................................................... 104


List of Abbreviations:

ACP – Advanced Care Planning

APRN – Advanced Practice Registered Nurse

AWV – Annual Well Visit

CAH – Critical Access Hospital

CCD – Continuity of Care Document

CCM – Chronic Care Management

CCW – Chronic Conditions Warehouse

CMA – Certified Medical Assistant

CMS – Centers for Medicare & Medicaid Services

CPCI – Comprehensive Primary Care Initiative

CPT – Current Procedural Terminology

EHR – Electronic Health Record

E/M – Evaluation & Management

ER – Emergency Room

FI – Fiscal Intermediary

FQHC – Federally Qualified Health Clinic

HCPCS – Healthcare Common Procedure Coding System

ICAHN – Illinois Critical Access Hospital Network

IPPE – Initial Preventative Physical Examination

IRCCO – Illinois Rural Community Care Organization

LPN – Licensed Practical Nurse

LSCSW – Licensed Specialist Clinical Social Worker

MAC – Medicare Administrative Contractor

MAPCP – Multi-Payer Advanced Primary Care Practice

MI – Motivational Interviewing

MWV – Medicare Well Visit

PA – Physician Assistant

POA – Power of Attorney

RN – Registered Nurse

RHC – Rural Health Clinic

TCM – Transitional Care Management

WMV – Welcome to Medicare Visit


INTRODUCTION

Welcome to Chronic Care Management (CCM). The following manual has been developed

using the most recent regulations surrounding CCM services, and incorporates

information made available by the Centers for Medicare & Medicaid Services (CMS). The

manual format has been designed to assist a practice setting through the CCM setup

process from beginning to end. It also provides explanations and definitions to areas of

CCM that can become confusing, as well as practice examples when necessary. It is

important to review the entire manual prior to beginning a CCM program. This will allow

for a thorough knowledge base to be established, and will allow practice settings to

develop any tools/processes that are needed.

CHAPTER 1 WHO CAN PARTICIPATE?

Care coordination programs have gained attention over the last several years from both

the healthcare community and governing bodies such as CMS. This attention stems from

the impact care coordination has had on improved patient outcomes, and reduced

healthcare related costs. Any provider may offer a CCM program, especially providers

working to improve patient outcomes in their chronic population.

Starting in 2015, CMS enabled providers to begin billing for CCM services under the code

“99490”. In 2016, CMS developed guidelines that allowed Rural Health Clinics (RHC) and

Federally Qualified Health Clinics (FQHC) to also bill for CCM services. CMS has identified

a list of providers who are considered eligible to bill for CCM services under their provider

number:

Physicians

Physician Assistants

Certified Nurse Specialists (Not eligible core providers in RHC/FQHC settings)

Nurse Practitioners

Certified Nurse Midwives

RHCs and FQHCs

Hospitals (Which includes Critical Access Hospitals)

Who may not bill for CCM services?

Licensed Clinical Social Workers


Clinical Psychologists

Any practice setting participating in a CMS sponsored model or

demonstration program:

o Multi-payer Advanced Primary Care Practice (MAPCP).

Patients are attributed to a practice under the MAPCP model.

Any patient not attributed to the MAPCP model can be offered

CCM services and the practice may bill for those services.

o Comprehensive Primary Care Initiative (CPCI).

Patients are attributed to a practice under the CPCI model.

Any patient not attributed to the CPCI model can be offered

CCM services and the practice may bill for those services.

Below is an outline of the most recent CCM regulations mandated by CMS. It is critical to

always stay informed of current CMS regulation changes, and to use the most up-to-date

information available. New rules listed in the Federal Registry from November 15, 2016

pertaining to CCM programs have been accounted for in the information provided.

Any providers who continue to question whether they qualify to bill for CCM services

should always verify eligibility with CMS, their Medicare Administrative Contractor (MAC),

or Fiscal Intermediary (FI) provider.

The following key elements will help providers determine if they are qualified to begin

billing for the CCM services they provide. Prior to CCM implementation or billing, all

current CMS regulations should be reviewed and discussed with the entire CCM team. If

it is determined there are CMS requirements that cannot be met, these items should be

resolved prior to moving forward.

1.1 Use of a CMS Certified Electronic Health Record (EHR)

Beginning January 2017, CMS made regulatory changes pertaining to the use of an EHR.

CMS is still requiring that a provider uses or has access to use an EHR, but they have

reduced the mandated uses to only a few items. A provider can always utilize an EHR for

as many aspects of CCM as they choose, but the following are the only items that CCM

mandates:

To record patient demographics

To record patient problems lists


To record patient medications lists

To record patient allergies

To retain copies of patient care plans (do not have to build care plan in EHR)

The EHR will have to meet current guidelines to be eligible for use in the CCM program.

CMS regulates that the EHR will need to meet the CMS certification standards as of

December 31st of the previous calendar year. Currently, the EHR in use should be certified

to the CMS 2014 editions of certification criteria. As we move forward in time, CMS may

require updated certification criteria. Because of CMS updates and evolving regulations,

it will be important to check for the current requirements for the EHR a practice is utilizing.

This can be checked by visiting: https://www.cms.gov/Regulations-and-Guidance/

Legislation/EHRIncentivePrograms/

1.2 Ability to Build a Comprehensive Care Plan

The CCM team will be responsible for electronically creating a patient-centered

comprehensive care plan for each CCM patient. CMS is not requiring the care plan to be

created using a certified EHR; only that the care plan information is captured electronically

and that a copy is stored in the EHR.

What does “create electronically” actually mean?

Healthcare providers who utilize a computer program to build patient care

plans are meeting this requirement.

The care plan may be completed on paper, but that information will need to

be transferred into an appropriate program on a computer.

o This allows for a copy of the care plan to be printed, emailed, faxed, or

uploaded into other systems, such as an EHR or a patient portal.

o It also allows for continued updating to the care plan by any care team

member.

The care plan created for each CMS patient will need to share common information that

CMS regulations require. CMS does not limit the information that populates a patient care

plan, but does require that the following information is present when the care plan is

completed:

Assessment of physical, mental, cognitive, psychosocial, functional, and

environmental needs

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/



Problem lists with symptom management, planned interventions, measurable

treatment goals, and expected outcomes and prognosis

Inventory of community resources and support—including already ordered

services

A description of how these services will be directed/coordinated outside of

the practice

Medications and medication management

Process for care transitions and coordination of outside services with agencies

and specialists

Assignment of who is responsible for each element of

interventions/treatments

Schedule for periodic review and, when applicable, revision of the care plan

The care plan will need to be made available to others outside of the billing provider.

Typically, this would include other healthcare providers involved in the patient’s care,

healthcare members/providers involved in the 24/7 access to care coverage, and

healthcare providers involved in transitions in care settings. This can be achieved by

sharing a printed copy, or by sending an electronic copy through patient portals, secure

email, EHRs, or faxing.

For more in-depth information on completing the care plan (See “7.2 Step 2: Begin Care

Plan” and “7.6 Step 6: Complete Care Plan”).

1.3 Ability to Provide CCM Patients with 24/7 Access to Care

CMS requires that every practice setting providing CCM services has a process in place

that allows CCM patients access to care on a 24/7 basis. This means that a patient should

be able to reach out to an individual who will help direct them to the care they need, no

matter the time of day, or day of the week. CMS has written this requirement as follows:

“Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified

healthcare professionals or clinical staff, including providing patients (and caregivers

as appropriate) with a means to make contact with healthcare professionals in the

practice to address urgent needs regardless of the time of day or day of week” (source:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/ChronicCareManagement.pdf)

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf



Interpretation of this regulation has caused some confusion. To understand the content,

it should be broken into two separate statements.

Provide 24/7 access to physicians, qualified healthcare professionals, or clinical

staff during normal business hours:

o Patient can connect with the practice during business hours.

o Patient’s basic and urgent needs can be addressed.

Provide 24/7 access to physicians, qualified healthcare professionals, or clinical

staff during non-business hours:

o Patient can connect with qualified healthcare personnel during non-

business hours.

o Patient’s basic needs can be addressed.

o Qualified healthcare personnel can receive patient’s care plan

information upon request from billing provider’s practice.

o Qualified healthcare personnel can contact a healthcare professional

from patient’s practice setting to address urgent needs.

Patients assigned to provider can be contacted.

Another provider/practitioner from same practice with

knowledge of patient’s needs can be contacted.

How a practice setting provides this access has not been mandated, only that the patient

will be able to access care whenever he or she may need it. All members of the care team

should sit down to discuss the practice settings options surrounding this requirement,

and decide what process would best meet the needs of that setting. The following are

examples of acceptable processes, with key notes to consider.

A group of providers within a shared practice rotate being on call. An after-

hours on-call service is in place that will receive the CCM patient calls that come

in for the practice setting. The on-call service then either redirects the patient

call to the provider, or contacts the provider with the patient information. The

provider then speaks with the CCM patient and provides the required assistance

needed.

KEY NOTE: All providers rotating call will need to either be knowledgeable

about each CCM patient’s needs, or have the ability to access CCM patient

information when needed.

A practice contracts with the local Emergency Room (ER) to help cover the after-

hours access to care requirement. The ER staff may consist of various qualified


healthcare professionals ranging from nurses up to physicians. A CCM patient

will call the ER to gain assistance with his or her basic needs. If the patient’s

needs are more urgent, the ER staff can provide the necessary assistance

following standard protocol. If the treatment options for those urgent needs

are not completely clear, the ER staff can contact a provider from the patient’s

practice setting for consultation. The ER staff will take guidance from the

practice provider to meet the needs of the patient.

o KEY NOTE: The qualified healthcare professional talking with the

patient needs to act within his or her scope of practice and job

description.

o KEY NOTE: All aspect of “Incident-to” rules apply to this setting,

meaning that an ER physician will need to give direct supervision

over the ER staff (auxiliary personnel).

o KEY NOTE: The ER physician or staff must have the ability to contact

the practice provider for consultation related to urgent needs.

o KEY NOTE: The ER staff will need to have access to CCM patient

information if the need arises.

1.4 Provide Patients Access to Successive Routine Appointments

All practice settings seek to improve quality outcomes while reducing unnecessary

treatment errors. A large percentage of errors stem from lack of knowledge about the

patient’s healthcare needs, or from miscommunication of information between the

patient and the healthcare provider. Unnecessary treatments and errors begin to reduce

when the healthcare team and patient work together.

CMS has required that the CCM patient will need to be able to consistently see the same

provider for all routine needs. It is also mandated that the patient will need to have timely

access to these routine appointments. To meet both needs, it is suggested that each CCM

patient should be assigned to a provider, and that all routine appointments with that

provider are scheduled ahead of time. The CMS regulation wording only includes the

patient’s routine needs, and does not seem to mandate the guidelines for acute or urgent

needs. A practice setting is only required to follow the regulations, but should consider

these suggestions:

A CCM patient should always see the same provider for all appointments.

o Provider becomes familiar with patient and patient needs.


o Patient has trusting relationship established with same provider.

o Includes routine and acute/sick appointments.

o Increases continuity of care and communication between provider and

patient.

o Reduces errors because of knowledge and consistency.

A CCM patient should always interact with the same care team member.

o Continues same continuity of care and communication parameters.

o Care team member builds rapport and trust with patient; will be.

knowledgeable about patient’s needs.

o Reduces errors because of knowledge and consistency.

Practices with multiple providers who consistently share patient loads will need to adjust

their current processes to meet this requirement. There will be instances where the

patient’s assigned provider is not available when the patient has an acute need. CMS has

not mandated that every appointment be with the same provider, as circumstances are

sometimes unavoidable. In that situation, it is important for the patient to receive the

necessary treatment, and scheduling with a different provider would be in the best interest

of the patient.

1.5 Process for Transitions in Care

It is important that patient information follows a patient no matter in what setting the

patient resides. Many times, a patient goes from one form of healthcare to the next, and

the staff involved are not aware of pertinent health information for that patient. Let’s start

by looking at the different types of transitions in care that a patient can experience:

Referrals to other providers or healthcare professionals

Switching to a new provider

ER visits

Hospital admission/discharge

Discharge from any healthcare setting to home (assisted living, nursing home,

etc.)

Admission from home to healthcare setting (assisted living, nursing home, etc.)

The CCM care team will need to implement a process that follows the patient during care

transitions, and improves the communication between all healthcare providers involved.

Communication with treating facilities/providers will allow care team members to collect


the patient’s medical information, medication changes, and any discharge planning. Part

of this process also needs to include the use of a Continuity of Care Document (CCD).

CMS regulation has mandated that a provider will need to create a CCD when a CCM

patient experiences one of the transitions in care listed above. The CCD is a tool that

should effectively communicate the treatment plans and needs for that CCM patient from

one healthcare provider to the next. Here is an outline to help understand the key

elements of a CCD:

CMS does not mandate that the CCD is created electronically. It can be hand

written, created electronically, or created within an EHR.

CCD is to be shared in a timely manner with other healthcare providers during

transitions.

o CMS does not define “timely”, but it should be shared within a

reasonable amount of time, allowing for the optimal treatment of that

patient.

o It can be shared through an EHR, secure email, secure faxing, or

solution of choice.

If you have a CMS certified EHR, then a CCD can be created from the EHR.

A transition in care process should also include steps that will enable the CCM team to

gather important information about changes in the patient’s treatment plan. The care

team should always follow up with the patient after any of the transitions in care listed to

see if the patient has any questions, if any new orders were received, and if any follow-up

appointments should be scheduled.

1.6 Provide Patient with Enhanced Communication Possibilities

Each CCM patient should have the ability to communicate with the provider and the care

team in an enhanced manner, and not just by telephone access. This can be achieved by

using a secure messaging system, electronic systems/programs, or asynchronous non-

face-to-face methods such as a patient portal. Provided that the patient can correspond

with the care team/provider in a manner other than telephone, this element of CCM will

be satisfied.


1.7 Provide Each CCM Patient 20 Minutes Non-Face-to-Face Time

CMS requires that each CCM patient receives 20 minutes of non-face-to-face time each

calendar month before a provider can bill for the CCM services. The 20 minutes of non-

face-to-face activities must be performed by the designated CCM provider, or the clinical

staff (care team members) that work under the CCM provider. CMS states their view as

follows:

“CCM services that are not provided personally by the billing practitioner are

provided by clinical staff under the direction of the billing practitioner on an

“incident-to” basis (as an integral part of services provided by the billing

practitioner), subject to applicable State law, licensure, and scope of practice.

The clinical staff are either employees or working under contract to the billing

practitioner whom Medicare directly pays for CCM.”

(See: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf )

Also see: “2.1 Assemble a Care Team”.

The clinical staff providing the activities that comprise the 20 minutes each month will

need to have a systematic way of recording these activities for tracking purposes. It is also

important to understand which activities can be counted toward that 20 minutes. More

information about these activities are available and located in the process sections (See

“8.1 What Activities Can Be Counted in Those 20 Minutes?”).

1.8 “General Supervision” to Care Team Members

Staff providing elements of the CCM services to the CCM patients, can do so under

general supervision guidelines. Formerly CMS required the CCM services to be provided

by clinical staff under direct supervision guidelines, but then CMS realized this became

more of a burden for practice settings when trying to implement all CCM service elements.

This new guideline also applies to both RHCs and FQHCs, but pertains to supervision

levels surrounding CCM services only, and not all practice setting services.




CHAPTER 2 HOW TO GET STARTED

The success of the CCM program begins with two key components: fully engaged CCM

care team members, and an accurate patient participation list. The practice setting needs

to appoint individuals to these components who will be both appropriate and fully

engaged. Let us look at these topics in a little more detail.

2.1 Assemble a Care Team

A lot of terms are used when discussing CCM. The term “care team” is used consistently

throughout all aspects of every CCM program. It is important to understand the

information that will best answer the question, “What is a care team?”. In general, the care

team can be any individual that is involved in the care of each patient. For purposes of

CCM, the care team definitions pertain to the practice setting that provides CCM services

to the patient. It is important to understand the elements that build the structure of a care

team. The following points outline information that explains a care team’s typical member

make up.

A patient enrolls into CCM services with one designated provider at a time.

CCM can only be billed under that one designated provider per calendar

month.

Care team members will provide CCM services under the guidance of that

billing provider.

Care team members can include:

o Billing provider that is assigned to the CCM patients.

o “Clinical staff” under the billing provider (See “*CPT defines clinical

staff” below).

Should only be clinical staff who are providing CCM services to

CCM patients.

Non-clinical staff cannot provide actual CCM services, but can

perform designated clinic duties that may intersect with CCM

patients.

o Incident-to providers/practitioners under billing provider.

o Incident-to contracted third parties who are contracted under the billing

provider (care management business, on-call service, contracted ER

arrangement).


o Care coordinator designated position.

A designated care coordinator:

o Will lead and organize all care team members and CCM program

activities.

o Will ensure all program requirements are met for each CCM patient

every month.

o Can be a member from the clinical staff.

o Can be a hired position.

o Should have CCM program duties only, as it is detrimental to CCM

success to pull a care coordinator into other duties.

KEY NOTE: CMS structure for CCM programs has loosened to allow for easier access

to services. It is not mandatory that all care team members reside inside the same

clinic walls to meet the guidelines CMS has established. A care coordinator or third

party can provide CCM from an alternate location, provided the following are true:

The care coordinator or third party has a contractual agreement with the

billing provider, or is a W2 hired employee.

All “incident-to” rules are followed when providing services.

o Billing provider must be available for direct consultation if need

arises.

o Billing provider takes full responsibility and oversight for the

services the care coordinator/third party will provide and execute.

Clinical integration exists between the care coordinator/third party, the

billing provider, and the practice setting.

o Communication of patient information must exist back and forth

between all parties.

o A process to address patient updates and needs must be in place

to ensure all parties remain knowledgeable of the patient

condition, and patient receives necessary services and treatments

when warranted.

CMS does not mandate a formalized structure for a care team, but does expect that all

required CCM components are followed per CMS regulations. Adding structure and

assigned duties to care team members will increase efficiency, decrease confusion, and

ensure monthly completion of CCM requirements to meet billing needs. Ultimately, an


organized care team is more knowledgeable, efficient, and effective at facilitating services

to meet the needs of each CCM patient.

*CPT defines clinical staff: “as a person who works under the supervision of a physician or

other qualified healthcare professional and who is allowed by law, regulation, and facility

policy to perform or assist in the performance of a specified professional service, but who

does not individually report that professional service.” Can include: APRN, PA, RN, LSCSW,

LPN, clinical pharmacists, and “medical technical assistants” or CMAs—directly employed

by a physician or physician’s practice.

2.2 Patient Eligibility

Up to this point it has been determined that the provider’s practice can fulfill the CCM

billing requirements, and all care team members have been assembled. Now it is time for

the care team to populate a list of patients who are eligible for CCM services.

For a patient to be eligible to participate in a CCM service, the patient must have at least

two or more chronic conditions. CMS has congregated a list of chronic conditions

available to view in their CMS Chronic Conditions Warehouse (CCW) (Go to

“www.ccwdata.org”). It is important to note that CMS does not limit what they consider

to be acceptable diagnoses to the ones shared in the CCW, but they must meet these

criteria:

(1) Chronic conditions will last at least 12 months or until patient death.

(2) They place the patient at risk for death, acute exacerbation, decompensation,

or functional decline.

It can be overwhelming to look through hundreds of patients with a large assortment of

chronic conditions to review. This is a time when it can be helpful to utilize any tool the

practice has available, or to try to minimize the overall diagnosis focus.

For example: a care team can utilize an EHR (or similar system) and perform a

search through the database for patient information, depending on the systems

functionality. The search could be focused on finding specific chronic

conditions, and would allow quick access to a large list of patients to begin

reviewing for CCM services.

For example: when reviewing the list of patients with the identified chronic

conditions, the care team may choose to focus on the diagnoses that are the

http://www.ccwdata.org/


most prevalent on the list. The care team may find that HTN, CHF, and DM have

the highest prevalence, and may decide to only focus on patients with those

chronic conditions. This would narrow the number of patients to be considered

for CCM services.

The care team may want to first sit down and decide which chronic conditions would

warrant higher consideration for CCM services than others. CMS provides a lot of

information throughout the CMS website surrounding chronic conditions, and the

prevalence that accompanies them. The care team should first determine what conditions

exist in that practice setting, and then access any resources available to help determine

the chronic conditions on which to focus. The table below shows the five most prevalent

dyads in the national population, as well as the top five dyads that cause the highest cost

to healthcare systems:

Five Most Prevalent Dyads Five Most Costly Dyads

High cholesterol + High blood pressure Stroke + Chronic kidney disease

High cholesterol + Ischemic heart disease Stroke + COPD

High cholesterol + Diabetes Stroke + Heart failure

High cholesterol + Arthritis Stroke + Asthma

Ischemic heart disease + High blood

pressure

COPD + Chronic kidney disease

Below is a 2014 Prevalence chart (the most recent for CMS) that can help providers

visualize common chronic conditions, and what percentage of prevalence they present.

This chart is just a visual tool to aid in understanding how chronic conditions present

themselves within the population. Each patient will need to be assessed individually to

decide if his or her chronic conditions meet the guidelines stated.


More information surrounding chronic disease data can be accessed by visiting the

Chronic Conditions Data Warehouse at: www.ccwdata.org. The site contains statistics and

charts that depict various chronic condition metrics. To view more chart information, you

would perform the following:

Go to tab “Medicare Data" and click

Go to “Medicare Charts” and click

Go to “Medicare Chronic Conditions Charts” and click

2.3 High Risk Patients

The next step is to review the list of eligible patients that has been populated by the care

team. This list could contain hundreds of names, or it may only contain a limited few. It is

necessary to review the list to determine which patients are at a higher risk for health

exacerbations, and which may benefit from CCM services more than other patients. Care

team members should come together to discuss patients, to utilize stratification tools,

and to decide on a final core group of patients to whom CCM services will be offered.

Several of the following items should be considered:

Has the patient had a new chronic diagnosis within the last 12 months?

Does the patient have four or more chronic conditions?



Does the patient have frequent ER visits/hospital admissions?

Will CCM services help reduce the patient’s risk for ER visits/ hospitalizations?

Is the patient noncompliant with medicine, treatments, or appointments?

Does the patient take 6 or more medications?

Does the patient’s condition require extra attention to improve compliance

and prevent exacerbations? Does the extra attention equal 20 minutes or

more per calendar month?

Does the patient have dementia? (usually not a target patient for CCM, but

not excluded)

Add questions tailored to your patient population…

What insurance does the patient have? (This question is not meant to exclude

anyone, but rather to determine if the patient has an insurance that will/will

not cover CCM services.)

o Medicare—covers CCM services.

o Medicare Advantage—should cover; need to verify for CCM services and

copays prior to starting, as they make payment adjustments and may

have different service requirements.

o Private insurance—always call to verify coverage for CCM services/

copay; if it is secondary, check copay coverage.

o Medicaid—call to verify coverage for services and copays.

CMS has no mandatory requirement outlining the stratification process, provided all

guidelines for chronic conditions are followed. It is important to identify patients that are

at risk for future health declines or illness exacerbations, as those patients will typically

receive the most health benefits from the CCM program you offer. Using the questions

above, a risk stratification tool can be developed to help identify patients who are at a

higher risk than others.

If the manual was accompanied by the “CCM TOOLKIT”, it will contain a tool labeled

“PATIENT RISK STRATIFICATION”. A care team can alter the tool to include any

information or questions that they feel are necessary for their patient population. If the

“CCM TOOLKIT” did not accompany this manual, and a practice setting is interested in

obtaining one, please contact ICAHN – IRCCO for further information.


2.4 How Many Patients Can Staff Handle?

Many factors will influence the final decision on the correct number of patients to whom

you offer CCM services. It is important to first understand and answer a few key process

items:

(1) What clinical staff is available to provide the 20 minutes of non-face-to-face

time and other service requirements to CCM patients?

(2) If current clinical staff is unable to accommodate CCM patients, should a care

coordinator be hired to be able to meet the necessary service requirements?

(3) Is outsourcing the care coordinator duties from a contracted third party an

option?

Whichever option (1-3) is decided upon, it is then necessary to determine how much time

that individual will have each calendar month to meet the needs of the program. At the

minimum, 20 minutes of time should be allotted for each patient, but typically it will

require closer to 30 minutes and sometimes more. It is highly recommended when

starting a new CCM program, that time allotments are kept higher than necessary, and

the number of program participants kept small. Moving forward, programs can adjust

both time and patient numbers to fit the growth of the service.

Here is an example: Judy is an RN in the office designated to care coordinate duties.

Judy and the care team decide to offer 100 patients the opportunity to receive services

through their CCM program. Following the suggested steps, they decide this key

information:

Judy will have 3 hours each day devoted to CCM duties (3 hours x 60 minutes

= 180 minutes).

Judy works full time 5 days per week (5 days x 180 minutes = 900 minutes per

week).

There are usually 4 weeks in a month (900 minutes x 4 weeks = 3,600 minutes

per month).

100 patients need about 30 minutes each per month (100 patients x 30 minutes

= 3,000 minutes per month to meet program needs).

Judy will have 3,600 minutes available per month to complete CCM duties, and

100 patients will require 3,000 minutes, so it is decided that 100 patients is a

safe number and will allow for unforeseen process items, errors, and issues, as


well as increased time needed for certain patients. As the program becomes

more efficient, the target number of patients can increase.

Judy is pulled between two jobs, which limits her ability to take on more

patients for the CCM program. Once payment begins to efficiently flow in from

the CCM program, hiring a full-time CCM Care Coordinator should be

considered.

The example above shows how time can be limited when a care team member performs

more than one duty within the practice setting. A practice setting can choose to assign a

clinic staff member to perform the CCM services, or a new applicant can be hired. It is

highly suggested that the person assigned CCM duties should only perform CCM services,

and not be pulled into other clinic duties. A dedicated clinical staff member will improve

the quality of the services provided as well as outcomes.

In the above example, Judy is limited by the time available to her each calendar month.

By limiting the number of patients that can be enrolled in CCM services, a practice setting

is also limiting the amount of reimbursement the CCM program can receive. A successful

CCM program should be able to cover the costs of the care team member/care

coordinator’s salary, and still have extra revenue after expenses. The self-sustaining ability

of the CCM program is important in determining its future longevity.


CHAPTER 3 ASSIGN PROVIDERS/CARE TEAM

MEMBERS

Once the core group of CCM patients has been aggregated, each CCM patient will need

to be assigned to one provider. That assigned provider will be responsible for seeing the

patient routinely, for educating the patient on initial CCM services, and for obtaining

written/verbal consent for CCM services from the patient. Since CCM services can only be

offered by one provider per calendar month, all CCM services for the patient will be billed

under that assigned provider. It is recommended that each CCM patient be assigned to

one care team member. The care team member will be responsible for routine

correspondence with the patient, to meet the 20 minutes of non-face-to-face time each

calendar month. It is also recommended that the patient corresponds with that assigned

care team member regarding all care needs moving forward.

Why is this important?

Continuity of care is mentioned throughout the CMS regulations regarding CCM services.

By assigning a provider and care team member, continuity of care can be achieved.

Assignment will help to organize the care delivery model for that CCM program, to

increase the familiarity with the patient’s health history and needs, and to build a trusting

relationship between the patient and provider/care team member. Fragmentation of care

can occur when too many healthcare providers randomly hand off treatment of the same

patient, and then fail to communicate effectively with each other. Providers and care team

members are not as familiar with a patient’s needs when they do not see him or her

routinely. The lack of patient familiarity, along with ineffective communication, can lead

to unnecessary treatments and treatment errors. Having the patient consistently see the

same care team members for routine appointments will help to reduce errors, avoid

unnecessary treatments, and improve overall communication among all involved parties.

Why is assigning providers/care team members important for billing?

Before CCM services can begin, each patient must consent to receive CCM services from

an assigned provider. The consent from the patient identifies the provider, and allows that

provider to bill for CCM services each calendar month. The billing department will use the

assigned provider number on each claim. This may be a single provider number or a group

provider number, depending on the process already established within the practice. It is

important that the same provider number is used each calendar month on the CCM billing


claim for each patient. If the provider number submitted on a claim changes, it informs

CMS that the patient is receiving CCM services from a new and different provider. This

would require proper documentation and completion of a new consent form to meet

CCM regulations (See “4.7 When is New Consent Required?”).

If the proper consent process is not followed to switch to a new provider, then the practice

setting will be out of compliance.


CHAPTER 4 PATIENT CONSENT

Obtaining patient consent for CCM services is not as simple as a quick “yes” or “no”. CMS

regulation stipulates certain that elements are required when obtaining consent from the

patient. The regulation outlines when and what type of appointments should be

scheduled, what CCM content to share with the patient, and what documentation is

necessary. CMS has allowed the consent to be obtained either verbally, or through a

signed consent form, from the patient. Either option is acceptable, provided that all

information shared with the patient, and the patient’s response, is charted in the patient’s

medical record. A practice settings policy and procedure process may help decide which

form of consent is appropriate to use.

KEY NOTE: CCM services cannot be initiated until all guidelines have been satisfied.

The patient must be fully educated on all CCM service elements and

process.

The information shared with the patient and the patient’s response to this

information must be documented in the patient’s medical record.

The patient must have given consent to receive CCM services from the

provider and the provider’s practice setting.

Patient consent is documented in the patient’s medical record, or a signed

consent form is completed and a copy retained for the patient’s medical

record.

The process that surrounds patient consent will differ depending on the visit history for

that patient, and whether he or she is an established patient with the provider. It is also

necessary to understand the information that CMS requires to be shared with each patient

when offering CCM services. The next several sections will provide information about

these topics.

4.1 What Must Be Discussed with the Patient?

CMS has outlined a lot of information pertaining to the discussion that will take place with

the patient. Some information is required, and some is suggested to be included in the

patient discussion. Each practice setting will need to identify what will be shared during

each CCM conversation with the patient.


The purpose of the CCM discussion with the patient is to provide a thorough knowledge

of what CCM means, what service elements are included, and which guidelines must be

followed. The provider/care team will want to build a trusting relationship with the patient.

A patient who feels knowledgeable and fully informed about the care he or she receives,

will feel a level of trust toward the healthcare team. Also, full disclosure will help to avoid

unexpected surprises to the patient during CCM services. When patients experience

surprises, they quickly assume that the provider/care team withheld important

information from them and essentially lied.

CMS regulation mandates that the content listed below must be shared with the patient

when discussing and then offering CCM services.

Discuss the nature of CCM services.

o Inform patient that CCM services are available.

o Explain what CCM services are and what they include.

o Explain what the CCM service will do for patient.

o Outline the different components that will be implemented/utilized:

Electronic Health Records,

Patient portals/electronic system—including interactive and

educational materials/modules,

Care transition process,

Communication among providers—continuity of care document,

Patient-centered care plan,

On call process or 24/7 coverage plans, and/or

Monthly interactions with care team member.

Explain how the different parts of the CCM services will be accessed.

o Patient portal/electronic system and access process—including texting,

emails, website address, etc.

o 24/7 access to care process with phone numbers.

Access during business hours.

Access during non-business hours.

Explain that only 1 provider can bill for CCM services per calendar

month.

o Patient can only give consent for CCM services to one provider at a time.

o Other healthcare providers may practice similar CCM care elements, but

CMS only allows 1 provider to bill for CCM services per calendar month.


o Patient may switch to another provider if he or she chooses, but must

follow guidelines.

The patient may stop CCM services at any time.

o Patient may decide to no longer be part of a CCM program.

o Patient informs current CCM care team/provider that he or she wishes

to stop services.

o Services will conclude and the end of that calendar month.

The content in this section is not considered mandatory, but it is strongly suggested that

the provider/care team incorporate this additional information into the CCM discussion.

Patient knowledge will increase, while unexpected service surprises will decrease by

including the following:

The patient will be responsible for any copayments that arise.

o Patient may assume CCM services are free to him or her, and therefore

be surprised to receive a bill for an unexpected copay, reducing trust and

possibly causing patient to withdraw consent for services.

o If patient does not have secondary insurance, he or she will be

responsible for a copay, typically around $8.00 for Medicare.

o Copay may be covered by secondary insurance, leaving no cost to

patient; inform patient that care team will verify with the insurance.

Most CCM services will be provided by “clinical staff” members of the

care team.

o Clarify at the beginning that patient will typically talk with clinical staff

and not the provider, in order to prevent mistaken patient expectations.

o Inform patient that the care team will always notify and update the

provider.

Outline expectations with the patient regarding the 20 minutes of non-

face-to-face time.

o Inform patient of the purpose and goals of non-face-to-face time:

Provide education,

Assess condition,

Assess treatment compliance,

Assess for any needed treatment changes or interventions, and

Provide medication oversight and management, etc.

o It may be helpful to schedule call times with patient in advance.


o Scheduling future calls with an expected start and stop time will:

Avoid patient expectations for how long patient has your

attention;

Encourage patient to organize information he or she wants to

discuss; and

Avoid upsetting patient when it’s time to end the call.

o Never stop a phone call discussion if patient issues are present.

Sometimes patient’s condition will require additional attention.

o Never make patient feel unimportant or a burden on time.

Some patients seek attention due to lack of other day-to-day

interaction.

Always assess patient emotional needs during these times.

Consider treatment options/resources if necessary.

o Outlining the purpose will help patient understand the expectations for

appropriate use of time prior to program starting, and encourage patient

to keep content pertinent.

The patient’s information will be shared with other healthcare providers.

o During care transitions, patient information will be shared via the CCD

and will include a copy of patient’s comprehensive care plan.

o Purpose is to increase knowledge about patient condition, improve

quality of care for patient, and to reduce unnecessary treatments and

treatment errors.

Explain how the patient’s information may be shared.

o Electronically such as secure email, secure faxing, etc.

o Through the use of an EHR.

CMS requires that all information that is shared with the patient is then charted in the

patient’s medical record. It is important to be thorough, and to make sure the charting

includes all mandatory and optional information as well as the patient’s responses. If a

consent form is utilized, it is necessary to chart any items that are not included on the

form. Thorough documentation will provide legal proof that all CMS guidelines were

followed, and that the patient gave informed consent to receive CCM services. For more

documentation information (See “4.6 Documentation of Consent”).


Now that the care team understands what information to share with the patient, it is time

to identify when and how to share it. The next sections identify the different types of

patients and the processes to follow when obtaining consent for CCM services.

4.2 A Brand New Patient

A brand new patient has secured services from the provider, and will begin coming to the

practice setting for healthcare. The care team reviews the new patient’s medical

information, and decides that the patient may benefit from CCM services. These steps

should be followed when offering the new patient CCM services.

(1) The provider/CCM team decides the patient meets CCM participation

guidelines.

(2) Schedule one of the following CMS approved face-to-face appointments with

the patient:

a) Medicare Well Visit (MWV)—Annual Well Visit (AWV),

b) Welcome to Medicare Visit (WMV)—Initial Preventative Physical Exam

(IPPE),

c) Evaluation/Management visit level 2 or higher (E/M), or

d) Transitional Care Management visit (TCM) if applicable.

(3) During the face-to-face visit, the provider makes the determination to offer

CCM services to the new patient. If the provider feels CCM is not appropriate,

the process stops here.

(4) The provider discusses CCM services with the patient during the face-to-face

visit, following all CMS guidelines; clinical staff may also be involved.

(5) The patient gives/refuses consent to receive CCM services.

a) If patient refuses CCM services, follow documentation guidelines and the

process stops.

b) If patient wishes to “think about it”, follow documentation guidelines

and schedule a follow-up phone call date with patient.

c) If patient gives consent to receive CCM services, follow documentation

guidelines and continue to (6).

(6) Review documentation in the patient’s medical record, making sure it includes

all information discussed with the patient, the patient’s questions or responses,

and patient consent/refusal.


(7) Follow up with the patient on the agreed upon date to inquire if he or she would

like to receive/refuse CCM services, and follow documentation guidelines.

a) If patient refuses services, process stops after documentation.

b) If patient agrees to receive CCM services, continue to (8).

(8) Patients who give consent to receive CCM services will need to begin the CCM

services setup process (See “7. WHAT HAPPENS AFTER PATIENT

CONSENT?”).

4.3 An Established Patient Not Seen in Last 12 months

The patients in this group are not brand new patients, but patients who are already

established with a provider in the practice setting. These patients do not typically see the

provider on a regular basis, and have not seen the provider within the last 12 months or

longer. This can be a difficult group to offer CCM services to. Some patients in this group

may be noncompliant with their healthcare, resistive to treatment options, or may have

existing barriers that prevent them from accessing routine care. All of this information

would have been considered during the risk stratification process. Offering CCM services

to this patient group will follow the exact same process as to “Brand New” patients:


guidelines.

(2) Schedule one of the following CMS approved face-to-face appointments with

the patient:

a) Medicare Well Visit (MWV)—Annual Well Visit (AWV),

b) Welcome to Medicare Visit (WMV)—Initial Preventative Physical Exam

(IPPE),

c) Evaluation/Management visit level 2 or higher (E/M), or

d) Transitional Care Management visit (TCM) if applicable.

(3) During the face-to-face visit, the provider makes the determination to offer

CCM services to the new patient. If the provider feels CCM is not appropriate,

the process stops here.

(4) The provider discusses CCM services with the patient during the face-to-face

visit, following all the CMS guidelines; clinical staff may also be involved.

(5) The patient gives/refuses consent to receive CCM services.

a) If patient refuses CCM services, follow documentation guidelines and

the process stops.


b) If patient wishes to “think about it”, follow documentation guidelines

and schedule a follow-up phone call date with patient.

c) If patient gives consent to receive CCM services, follow documentation

guidelines and continue to (6).

(6) Review documentation in the patient’s medical record, making sure it includes

all information discussed with the patient, the patient’s questions or responses,

and patient consent/refusal.

(7) Follow up with the patient on the agreed upon date to inquire if he or she would

like to receive/refuse CCM services; follow documentation guidelines.



(8) A patient who gives consent to receive CCM services will need to begin the

CCM services setup process (See “7. WHAT HAPPENS AFTER PATIENT

CONSENT?”).

4.4 An Established Patient Seen in Last 12 Months

Established patients may have represented a higher percentage of patients on the original

target list. Since the patient sees the provider more frequently, the provider and care team

will be more familiar with that patient’s chronic conditions. This familiarity with current

conditions and overall health makes it easier for a care team to identify whether a patient

qualifies for CCM services or not. Offering CCM services to this patient group should

follow these steps:


guidelines.

(2) Determine if the patient completed one of the following face-to-face

appointments in last 12 months:

a) AWV/MWV,

b) WMV/IPPE,

c) E/M level 2 or higher, or

d) TCM visit.

(3) If the answer to (2) is NO, stop and follow steps for (See “4.2 A Brand New

Patient”).

(4) If the answer to (2) is YES, continue to (5).


(5) Review the documentation in the patient’s medical record from the qualifying

visit to determine if a CCM discussion already took place, and if supportive

documentation is in place. To prepare for the conversation, the provider can

review previous information or provide all new information.

(6) The next contact with the patient will be via telephone.

a) Ask patient if CCM services have already been discussed with patient.

i) IF YES: Review previous CCM discussion notes and review all CCM

components; document entire discussion to meet requirements

(See “4.1 What Must be Discussed with the Patient?”).

ii) IF NO: Give complete explanation about CCM services as outlined

previously; document to meet requirements (See “4.1 What Must

be Discussed with the Patient?”).

b) If patient states full understanding of CCM services continue to (7).

c) If patient has more questions or does not understand what CCM services

are, it may be beneficial to schedule patient for a face-to-face visit to

discuss CCM further; document all discussions.

(7) Offer CCM services to the patient to obtain acceptance/refusal of services,

document the full discussion in the patient’s medical record, including

acceptance or refusal.



(8) A patient who gives consent to receive CCM services will need to begin the

CCM services setup process (See “7. WHAT HAPPENS AFTER PATIENT

CONSENT?”).

4.5 The Patient is Incompetent to Sign Own Consent

When a patient is deemed incompetent to give consent for medical treatment, it is

important to follow appropriate policies when obtaining written/verbal consent for CCM

services. The process for obtaining consent for CCM services for an incompetent patient

will follow whatever category the patient falls into above. The difference will be that the

patient’s legal representative (POA, Health Surrogate, Legal Guardian, etc.) should be

included in the entire process. Once all the steps are completed, then written/verbal

consent will need to be obtained from the patient’s legal representative. When abiding

by applicable state law, it will most likely be advisable to obtain a signed consent form


rather than charting verbal consent. It is crucial that this documentation is thorough, and

that the same documentation guidelines are followed for this scenario (See “4.6

Documentation of Consent”).

4.6 Documentation of Consent

The following information summarizes what content must be documented when

discussing and offering CCM services to the patient. It combines the content provided

above, along with current CMS documentation requirements. Currently, CMS does not

have a mandated process for the CCM documentation. A practice setting can choose to

chart electronically (such as inside an EHR), to write by hand into the patient’s medical

record, or to utilize whatever process fits the practice workflow. No matter which process

a practice setting chooses, it is crucial that the correct documentation takes place prior to

initiating CCM services. When discussing CCM services with the patient, it is necessary to

document these key components:

Document the information that the provider/care team reviewed with the

patient.

o Include conversations that are face-to-face or via phone.

o Include all mandatory content outlined in section “4.1 What Must be

Discussed with the Patient?”.

o Include any other content that falls outside the mandatory information,

such as the suggested content in section “4.1 What Must be Discussed

with the Patient?”. (This is not mandatory to include but is strongly

suggested for thoroughness)

o Documentation does not have to be word for word, but should include

key information that can easily be interpreted by the reader.

Document the patient’s understanding of all information discussed with

him or her.

o Should include patient’s statement of understanding, such as “fully

understands” or “states full knowledge”.

o Should include statement that accounts for question/answer times, such

as “Patient’s question answered with no further questions at this time”.

o Should include whether educational tools or handouts were used or

given to patient.


Document the patient’s acceptance or refusal to receive CCM services.

o Should state patient’s response if possible, such as “No I do not want

that”, “I accept”, or “I am going to think about it”.

o If patient provides a reason, it is helpful to include it.

If the patient is incompetent to give consent for CCM services:

o Document that patient is deemed incompetent to give legal consent for

CCM services.

o Include in documentation who the patient’s legal decision maker is and

his or her title (POA, Health Surrogate, Legal Guardian, other).

o Follow steps (1), (2), and (3) above; include in documentation that the

legal decision maker was involved and content provided/reviewed with

him or her.

o Documentation should include legal decision maker’s responses.

Keep in mind that the above list shares current CMS documentation requirements for a

CCM program. CMS continues to update and change those guidelines periodically. It will

be important to follow a resource that can keep your care team up to date on current

regulations as they evolve and change. The following are a links to the CMS and the

Federal Registry websites (www.cms.gov , www.federalregister.gov ). These are going to

be the most reliable resources for finding correct and up to date information.

4.7 When is New Consent Required?

The patient gives consent to the provider at the initiation of CCM services. That consent

binds the CCM patient to that designated provider, and allows that provider to bill for

CCM services every calendar month. CMS does not require the consent to be updated or

renewed, for as long as the patient continues to receive CCM from the same provider.

One documented consent process could essentially last for the lifetime of the patient,

provided that the following are true:

The patient willingly chooses to continue receiving CCM services.

The patient maintains full cognitive ability to make competent health decisions.

The patient continues receiving CCM services from the same designated

provider.

The patient is alive and able to be actively and mentally involved in the CCM

program.

http://www.cms.gov/

http://www.federalregister.gov/


Patient circumstances and health can change over time. It is important for the care team

to monitor the patient’s ability to meet the above criteria. Also, changes may occur which

do not involve the patient, but can affect the delivery of the patient’s CCM services. The

care team will need to be able to identify when change occurs, and if it requires that a

new consent process is initiated. The following are situations that should prompt the care

team to obtain new consent:

The patient is new to CCM services—new consent process is followed.

The patient was in CCM services and then revoked services for a short period

of time—new consent process is followed to restart.

The patient revokes CCM services with the current provider and decides to

switch to a new provider.

o Follow steps below depending on whether new provider is within same

practice or not.

o New consent can be dependent on billing NPI/TIN numbers.

A provider leaves a practice setting and is unable to continue to provide the

patient’s CCM services—the patient chooses a new provider for CCM services

and follows the new consent process.

A provider retires from practice and is unable to provide the patient’s CCM

services—the patient will need to choose a new CCM provider and follow the

new consent process.

The patient’s cognitive ability declines, and he or she becomes incompetent to

make decisions—the provider will obtain new consent from legal representative

for the patient.

The following information outlines the steps that need to be taken when CCM services

are interrupted, and when new consent is needed. Various scenarios can take place that

will require a different process to be performed to meet CMS regulations. It is also

important to make sure all documentation in the patient’s medical record clearly states

the events that take place.

The patient decides to revoke current CCM services.

o Patient informs provider/staff he or she no longer wishes to receive CCM

services.

o Patient decides to no longer receive CCM services from any provider.

Inform patient CCM services will stop at the end of current

calendar month.


Provider/staff chart in patient’s medical record:

Patient’s wish to revoke current CCM services from

current provider;

Patient’s reason for revoking, if one given; and

All conversation elements that take place.

Final claim for CCM services can be submitted at end of calendar

month, provided all service requirements completed.

o Patient decides to seek CCM services from a different provider.

Inform patient that CCM services with current provider will stop

at end of current calendar month, not on day of revocation.

Inform patient that new provider can begin CCM services on the

1st of the following calendar month.


Patient’s wish to revoke current CCM services from current

provider;

Patient’s reason for revoking, if one given;

Who patient has chosen as new provider for CCM services;

and


Current provider should attempt communication with new

provider.

Provider/staff may reach out via telephone or electronic

systems.

“Continuity of Care Document” and copy of patient care

plan should be sent to new provider.

Process should follow all HIPAA and patient consent rules.

Final claim for CCM services submitted at end of current calendar


Patient will follow new consent process with new provider.

The patient’s current CCM provider retires/leaves active practice.

o Retiring/leaving provider informs patient they are leaving practice.

o Patient decides to no longer receive CCM services from any provider.

Inform patient CCM services will stop at end of current calendar

month.



Patient’s current provider is retiring/leaving;

Patient chooses to revoke any further CCM services;

Patient’s reason for revoking, if one given; and


Final claim for CCM services can be submitted at end of calendar


o Patient decides to seek CCM services from a different provider.


at end of current calendar month, and not on day of revocation.




Patient’s current provider is retiring/leaving;


and


Current provider should attempt communication with new

provider.

Provider/staff may reach out via telephone or electronic

systems.

“Continuity of Care Document” and copy of patient care

plan should be sent to new provider.

Process should follow all HIPAA and patient consent rules.

Final claim for CCM services submitted at end of current calendar


Patient will follow new consent process with new provider.

The patient decides to switch providers within the same practice.

o Current provider number for billing CCM services will not change.

For example: provider may be using group number for practice

instead of individual number.


Patient’s reason for switching CCM providers;


and



Recommended to obtain new consent from patient for new

provider even if provider number is not changing (follow new

consent process outline).

Old and new providers discuss patient for continuity of care.

Stop and start of care will not be a concern, as billing will be under

same provider number; services continue without interruption.

o Current provider number used for billing CCM services will change.

For example: practice is using individual provider numbers—

switching to new provider’s individual number for billing.


at end of current calendar month, and not on day of request for

switch.



New provider follows new consent process to obtain consent

from patient.


Patient’s reason for switching CCM providers;


New consent process and patient acceptance/refusal; and


Current provider communicates with new provider for continuity

of care.

Submit claim for CCM services under old provider’s NPI at end of

current calendar month, provided all service requirements

completed.

CCM services begin under new provider, and claims will be

submitted using new provider’s NPI beginning the 1st of the

following calendar month.

A patient already receiving CCM services is deemed incompetent.

o If patient entered into consent for CCM services under a competent

mind, once deemed incompetent to make own medical decisions,

former consent process is no longer valid.

o Current CCM services can be billed at end of current calendar month,

provided all service requirements completed.


o Provider/clinical staff should reach out to patient/patient’s contacts to

see if legal guardian is going to be appointed for patient’s decision

making.

o All applicable HIPAA and state laws should be followed during this

process.

o Legal guardian is identified.

Obtain copies of legal paperwork for patient’s medical record.

Follow new consent process with patient and legal guardian.

Follow all documentation elements as outlined above, include

information shared with legal guardian, conversation elements,

and responses.

CCM services will commence as before with legal guardian’s

consent.

If guardian refuses services for patient, document and services

stop.

o No legal guardian is identified.

Provider/clinical staff document:

Patient’s new identified incompetence, and

Patient’s lack of legal guardian.

CCM services can continue for patient, but a claim for

reimbursement cannot.

For best interest in patient’s care, it is suggested that

services continue for as long as patient can participate

and will benefit.

Documentation will need to be thorough.

Several of the outlined processes above are centered around a competent patient who

initiates his or her own health services. For a patient who is considered incompetent to

make medical decisions, the same process can be utilized, but where it depicts “patient”

the term “legal guardian” would be substituted. CCM services cannot be performed by a

practice setting without proper consent when delivering those services to an incompetent

patient.

The process for obtaining consent may seem a little overwhelming at first, due to the

number of patients who need to be contacted. It will be essential to develop tools that

will help the CCM team keep information organized, and easily accessible (See “5.


ORGANIZING INFORMATION AND TOOLS”). Once the program is established, adding

patients will become easier because of lower numbers and familiarity with the overall

process.


CHAPTER 5 ORGANIZING INFORMATION

AND TOOLS

As the care team begins to contact patients and initiate CCM program elements, a lot of

information will begin to accumulate. It is essential to organize this information into

content that all care team members can fully understand, and can easily access.

Developing and utilizing organizational tools will help to bring all CCM information into

a usable format that will increase efficiency, and reduce process errors. No matter what

process is implemented, all care team members will need to consistently use the same

tools.

The following are suggested (not required) key areas for which the CCM team may want

to use some type of organizational tool. Each area provides suggestions on which tools

can be utilized and explains what each tool helps to accomplish. ICAHN – IRCCO tools are

also mentioned under each section. If the manual was accompanied by the “ICAHN –

IRCCO CCM TOOLKIT”, the tool mentioned will be located within that toolkit. If the “ICAHN

– IRCCO CCM TOOLKIT” did not accompany this manual, and a practice setting is

interested in obtaining one, please contact ICAHN – IRCCO for further information.

Target patients for CCM services—The first list of patients the team generates

contains names of patients who qualify for CCM services, but not the final list

to whom CCM is offered.

What to use:

o Suggest simple spread sheet or long form, electronic or written format.

o Can utilize printout from EHR or other source.

Patient risk stratification—Key questions are used to identify different health

risks. Answers help to identify patients whose health issues are more complex,

have a higher risk for health exacerbations, and whose condition demonstrates

the need for CCM services. This narrows the target patient list and identifies to

whom to offer CCM services.

What to use:

o Develop personalized tool, incorporating target questions that identify

risk factors for patient population. Can utilize printed or electronic

format. Refer to “2.3 High Risk Patients” for information on suggested

questions.


o ICAHN – IRCCO tool: “PATIENT RISK STRATIFICATION”.

CCM setup—This tool identifies required steps that need to be in place before

a patient is enrolled and ready to receive monthly CCM services. It will track

completed elements and allow the care team to identify when the patient is

ready to begin services.

What to use:

o Develop personalized tool; include all steps required before patient can

actively receive monthly services.

o ICAHN - IRCCO tool: “CCM SETUP TOOL”.

Program preparation—This simple tool identifies all the elements that CMS

requires before a practice setting can offer CCM services. It identifies when all

required elements have been completed, and the practice setting can move

ahead with the CCM program.

What to use:

o Suggest simple checklist, making sure to consult all current CMS

requirements and including each element in checklist. Section 1 and 2 in

the manual should be included, making sure process in place for billing,

care team assembly, tool building, processes mapping, etc.

o ICAHN – IRCCO tool: “PROGRAM PREPARATION” checklist tool.

Monthly CCM services—Develop a way to track monthly CCM activities for

each patient and identify cumulative time totals for those activities. This can

help the care team identify when 20 minutes of non-face-to-face time is

reached, and to notify the billing department.

What to use:

o Suggest formalized tool; easier to use electronic tool that allows

printing/saving and can be reused. Tool needs to include all areas to

clearly outline how 20 minutes are accumulated each month.

o ICAHN – IRCCO tool: “CCM MONITORING TOOL”.

Billing CCM each month—Create a way to track and identify when a patient’s

CCM services can be billed, and whether billing has been completed for each

patient, each calendar month.

What to use:

o Simple process that will communicate between care team and billing

department. An activity log that prompts care team to notify billing when


20 minutes reached is helpful. Electronic flow sheet is recommended for

easier input, printing, reading, and less waste.

o ICAHN - IRCCO example/usable tool: “CCM MONITORING TOOL”.

Patient-centered care planning—This is a tool that will utilize all of the

patient’s problems lists, personal needs and interests, psychosocial needs,

community resources, and chronic and acute conditions into one care plan (See

“1.2 Ability to Build Comprehensive Care Plan”). The tool should promote

patient involvement and give a clear picture of what plan of care should be

followed to meet each patient’s needs.

What to use:

o Electronic system that will enable the building and altering of a patient

care plan format. System should allow for care plan to be individualized

for each patient. Can be started on paper and then transferred into

electronic system—paper allows patient to manually input information

from home.

o ICAHN – IRCCO tool: “PATIENT-CENTERED CARE PLAN”.

Process checklists—This tool allows tracking of different CCM steps that

should be followed for the different service elements. It can include any topics

that the practice setting wishes to target. ICAHN-IRCCO utilizes check lists for

tracking whether all elements are in place to be able to move forward with the

CCM program, and patient setup steps.

What to use:

o Simple checklist—can be paper or electronic; can be built using practice

setting’s choice of systems (For example, “Microsoft Word”, etc.).

o ICAHN – IRCCO tools: “PROGRAM PREPARATION”, and “PATIENT READY

TO PARTICIPATE”.

ICAHN – IRCCO developed tools, if included, were developed to assist care teams in the

overall CCM process, while saving time on tool development. These adjustable tools can

be used at the care team’s discretion, and can be altered to meet the needs of different

patient populations. Care teams should feel free to add or change any components

necessary to achieve optimal function.

The following list of resources are provided so that practice settings are aware of other

tools and programs available for use in the CCM process. This is not considered to be an

all-inclusive list, but it does include resources that contain useful information. Some of


the sources below are direct links to CMS, and should be utilized first to obtain the most

accurate, up-to-date information on CCM services. None of these tools are considered

mandatory, but have been made available for easier access to added resources:

Centers for Medicare & Medicaid Services:

o Physicians Fee Schedule Look Up:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PFSLookup/index.html?redirect=/pfslookup

o General Website: https://www.cms.gov/

o CCM page: https://www.cms.gov/About-CMS/Agency-

Information/OMH/equity-initiatives/chronic-care-management.html

o TCM fact sheet MLN page: https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/Transitional-Care-Management-

Services-Fact-Sheet-ICN908628.pdf

Improving Chronic Illness Care resources and tools:

http://www.improvingchroniccare.org/index.php?p=CCM_Tools&s=237

Bizmed Toolbox sign up for free account/ contains CCM tool:

https://www.bizmedtoolbox.com/Account/Login.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PFSLookup/index.html?redirect=/pfslookup


https://www.cms.gov/

https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/chronic-care-management.html

https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/chronic-care-management.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf







CHAPTER 6 INITIATING CCM SERVICES

A lot of work has been accomplished up to this point, and the practice setting’s CCM

program is starting to take shape. Things will start to move forward more quickly now, as

the care team members began to reach out to the target list of patients. A review of the

items that have been completed by the care team, should look as follows:

The practice setting can provide all the required CCM service elements listed

by CMS.

A care team was assembled and a care coordinator was identified (if so chosen).

Patients who qualified for CCM services were identified.

Qualifying patients to whom CCM services may be offered were narrowed

down to a target list.

Target patients have been sorted into 2 groups.

o Needs qualifying (AWV, IPPE, E/M, or TCM) visit scheduled.

o Does not need visit scheduled—contact patient by phone.

Each patient has been assigned a provider and care team member.

Care team members were educated and understand the following CMS

requirements:

o What CMS requires when discussing CCM services with patient;

o That consent is needed from patient prior to initiating CCM services, and

when consent must be obtained/redone; and

o That CMS requires thorough documentation of CCM discussion with

patient in patient’s medical record; include patient’s consent/refusal.

The care team identified and then developed tools for use in the CCM program.

The entire team is fully knowledgeable on these tools and where to access

them.

The care team is ready to begin reaching out to patients on the target list, but

need to identify a few process solutions (discussed in next section).

6.1 Preparations Before Calls

Before the care team can begin to call patients, a few key items should be discussed as a

group if they have not already. The care team discussion should center around the CCM

program, and how each piece of the program will be implemented. This will help to

identify areas where there is no clear direction on how to implement a service element,


and whether a standardized process still needs to be developed. If there is no identified

process, then the care team will need to develop a solution before contacting any patients.

The following list of items should have a formal process in place that the care team can

identify.

What paperwork/information will each patient be required to complete?

Will the paperwork be mailed to the patient prior to his or her appointment,

handed to the patient at check-in, or made available to the patient via an

electronic source?

Will a “Patient-Centered Care Plan” or another type of care plan be utilized?

Will it be on paper, within an electronic source, or both?

Will the care plan be mailed to the patient prior to the appointment, handed to

the patient at check-in, or made available to the patient via an electronic

source?

Does the care team have a tool that will outline what is going to be discussed

with the patient during a phone call? Should a scripted outline be developed

to maintain consistent and complete information throughout the care team?

Each item mentioned above will affect the process that takes place when contacting the

patient. The care team will need to know what forms are being utilized, so they can explain

the forms to the patient and identify when they should be completed. This allows the

patient to ask questions, and will help to avoid anger and frustration about confusing and

lengthy forms. It will also help the care team assess whether the patient will be able to

complete the paperwork independently. Mailing forms to the patient to fill out at home

can be beneficial, as it is more efficient and can give the patient time to review the

information thoroughly. This may then prompt the patient to compile a list of questions

to ask about items he or she does not understand.

KEY NOTE: All forms that are mailed to patients should be tracked. This will help to

avoid duplications and missed patients.

One form to consider mailing is some type of care plan form (See ICAHN – IRCCO tool:

“PATIENT-CENTERED CARE PLAN”). The form should collect information from the patient

that will be utilized in formatting the final care plan. This allows the patient to be involved

in his or her own care plan process, and helps meet the CMS requirement of a patient-

centered care plan. The care team will review the information the patient provided during

the scheduled initiating visit, or over the phone if an initiating visit was not required.


As mentioned, the care team may choose to outline the conversation that will take place

when calling each patient. An outline of key CCM discussion points will ensure that each

patient hears the same information, and that required information is not left out of the

conversation. Practice settings can choose to compile a simple list of topics, or a detailed

list of specific items that would be reviewed during the CCM discussion. It may also be

helpful to include scripted conversations that can aid the care team during difficult topics.

6.2 Scheduling Appointments / Contact by Phone

Now it is time to pull out the CCM target list, to begin reaching out to qualifying patients.

Refer to sections 4.2 thru 4.5 to make sure each patient is categorized properly, and that

the care team understands the steps to follow. Make sure all care team members are

educated on any tools that will be utilized during this process, and know how and where

to access them. Also, make sure the care team can identify which provider is assigned to

each patient. This will allow for the process to run smoothly; otherwise, patients would

have to wait on hold while the team identifies who a provider should be.

Remember to follow the process outlined in sections 4.2 thru 4.5, but to also consider that

each patient call may not go as smoothly as planned. When making the calls to patients,

the care team should be prepared for four types scenarios. The following is a list of these,

and some of the situations that can happen during the phone call process.

Patients who need an initiating CCM appointment scheduled:

The patient may have never heard the term “Chronic care management”.

o Stay calm and briefly explain what CCM means.

o Explain provider feels patient would benefit from these services.

o Let patient know provider will discuss CCM thoroughly at appointment.

o Goal is to bring patient in for appointment where provider can more

thoroughly explain CCM to him or her.

o This is when scripting can be beneficial.

If the patient agrees, schedule the initial appointment.

Explain the paperwork the patient will fill out, and when it should be completed.

Consider mailing educational material to the patient prior to the appointment.

Remind the patient to bring paperwork, copies of insurance cards/advanced

directives, etc.

Document all conversation points in the patient’s medical record.


Patients who don’t need an appointment, but require CCM education:

Review the patient’s chart to determine if CCM has been discussed with him or

her.

Give a quick CCM review to the patient to obtain his or her knowledge level, as

the patient may not remember discussing CCM services.

The patient may not know what the term “Chronic care management” means.

o Give complete review of CCM services to patient.

o Inform all content as identified (See “4.1 What Must Be Discussed

with the Patient?”).

o Inform patient about paperwork, when to complete, and if mailing to

them.

The patient may state a complete understanding of the information shared with

them.

o Document conversation, knowledge level, and consent/refusal in

patient’s medical record.

o Mail paperwork to patient if necessary.

o Enter patient into system, spreadsheets, etc. as CCM patient if consent

given.

The patient may be confused and request to see the provider to discuss CCM

further.

o Review chart to see what appointments are scheduled next or needed.

o Great time to schedule yearly AWV if not already done.

o If not able to schedule AWV, IPPE, or TCM—go with next scheduled

E/M visit.

o Inform patient that paperwork will be mailed and should be completed

before appointment.

o Document conversation in patient medical record.

Patients who are very confused about why the care team called them:

This can happen with patients from #1 and #2.

After following steps in #1 and #2, a patient may still be confused no matter

how much information was shared about CCM.

If the patient agrees, schedule a qualifying appointment to discuss CCM further

with the provider. Even if a qualifying visit is not required, it is ok to schedule

one, following the guidelines.


Consider reaching out to any identified family in the patient’s medical record;

the patient should have given consent to discuss his or her medical information

with that family member. Follow all policy and procedures for practice setting

(HIPAA, etc.).

Document the conversation in the patient’s chart.

Patients who refuse to comply/listen, do not want to discuss further:

It is ok for a patient to refuse CCM services, as they are not mandatory.

Some patients do not like change or to try new things. Attempt to offer

alternate explanations or to send extra education to the patient.

Remain calm and polite and attempt to follow the steps, even if the patient is

rude. The patient is not angry with you.

Document the conversation in the patient’s chart, and include all education

shared and the patient’s reason for refusal.

Continue through the target list until each patient has been contacted, and the necessary

steps have been followed. Once the list is finished, every patient should either be

scheduled for an appointment, enrolled into the CCM program, or have the refusal to

accept CCM services documented in his or her medical record.


CHAPTER 7 WHAT HAPPENS AFTER PATIENT

CONSENT?

Many of the next steps will differ for each practice setting based on the systems utilized,

the tools constructed, and the technology that is available. Keep in mind that each process

step is designed to accommodate various care delivery models, but is only a suggested

option that can be altered to meet the needs of individualized CCM programs. Items that

are mandatory per CMS regulations will be identified as such.

At this point, it is assumed that the patients are either completing the initiating CCM office

visit, or have consented to receive CCM services during the care team phone call. The next

step begins the process of what needs to be done with each CCM patient who has agreed

to be part of the CCM program.

7.1 Step 1: Review and Set Up Enrollment

A patient will benefit from CCM services provided they become engaged in the process,

and fully understand how the entire process will work. Talking face-to-face with the

patient usually produces the best results, but may not always be possible. The best time

to consistently do this will be following the initial CCM setup visit while the patient is still

in the office.

The purpose of the face-to-face discussion is to provide an overall review of each CCM

component, and to identify the responsibilities the patient will have. This step may have

already been completed over the phone when the patient gave consent, but if not, the

care team can call the patient back to provide the information. The following information

will be reviewed with the patient who just completed his or her initial CCM visit, and/or

has given consent to CCM services.

(1) Review CCM services with the patient.

a) Reference conversation with provider (if applicable).

b) Ask if patient has questions.

c) Review highlights of CCM program and remind patient importance of:

i) Contact with care team each month,

ii) Interactions with systems (if applicable), and


iii) Copays and insurance coverages.

d) Make sure patient acknowledges full understanding.

(2) Review and set up patient access.

a) 24/7 access to care—review process and provide phone numbers.

b) Set up patient in patient interactive system with access information

(patient portals, electronic systems, EHR, other systems of choice).

(3) Review all interactive communication that will commence.

a) Review that care team member will call patient each month.

i) Set up date and time and identify which phone number to use.

ii) Review importance of receiving calls and being involved.

b) Educate patient how system will communicate with them (if

applicable)—texting, emails, phone calls, other.

c) Assess patient’s ability to use technology.

i) Provide education if available.

ii) Involve caregiver if patient allows.

iii) Develop alternative if unable to use technology (such as mail).

(4) Discuss the care plan with the patient (See “7.2 Step 2: Begin Care Plan”). a) Review goals and interventions identified (if available).

i) Inform patient of importance to follow goals/interventions. ii) Inform patient to communicate problems with care team.

b) Ask for any copies of advance directive paperwork (if applicable).

c) Provide diagnosis-related education materials.

d) Document when patient states full understanding of information

reviewed.

(5) Record and document all time spent with the patient, by the care team,

as related to CCM setup. These activities will count towards the first 20 minutes of current month.

After talking with the patient, make sure to record any important information that the

patient shared with you, as well as personal preferences that are identified. Places where

this information should be recorded may include: the patient’s medical record, the EHR,

the patient portal, or any structured paperwork being utilized by the care team.

There will be face-to-face activities that can be counted in the 20 minutes of non-face-to-

face time each calendar month. The time spent with the patient performing the activities


in this section can be counted toward that accumulated 20 minutes. Make sure the care

team knows to track the minutes spent with the patient during this initial CCM setup time.

7.2 Step 2: Begin Care Plan

The care plan is the most important tool utilized by every healthcare provider and care

team member in caring for the patient. It is not mandatory that the care plan is finished

during the patient’s initial setup visit, but it will reduce errors and increase the overall

quality if it is. However, it is mandatory that the final care plan is completed before CCM

billing begins.

Whether using a paper or electronic form of the care plan (See ICAHN – IRCCO tool:

“PATIENT-CENTERED CARE PLAN”), collaboration between the patient, provider, and care

team is crucial when populating each care plan section. The care team member needs to

meet with the patient after the provider has finished seeing him or her, and review the

information that the patient shared. At this point the care plan form should be mostly

completed, especially if one was mailed to the patient prior to the visit. The care team

member can reach out over the phone to address this step with patients who do not

require a visit. If an electronic care plan is going to be utilized, it should already be open

and started. Some practice settings may decide to have the patient fill out a paper copy

of the care plan, and then use that information to complete the electronic care plan within

their system.

KEY NOTE: Patient participation is vital in the care plan process. It encourages the

patient to become actively engaged in his or her own care, and increases the overall

success of the CCM program. The care plan should never be filled out by a care team

member at a desk without any patient involvement.

With the patient either present or on the phone, the care team member should review

each section of the care plan. Remember to write down patient input so that it can be

incorporated into the appropriate sections such as goals and interventions. The content

below explains the information that needs to be collected for a thorough care plan, and

explains why it is being collected. The format follows the sections in order from the ICAHN

- IRCCO CCM tool: “PATIENT-CENTERED CARE PLAN”, with condensed snapshots of each

section provided as reference:


PERSONAL CONTACT INFORMATION

o Allows standard collection of information for contacting patient

o Identifies patient’s ability to use technology, preferences, and education

needed for these systems

o Allows resource for alternate care team members to contact patient

correctly if needed

ALTERNATE CONTACT INFORMATION

o Identifies other individuals involved in patient’s care

o Identifies who should be called as stated by patient

o Easier access to important contact numbers for care team

o Helps avoid confusion surrounding legal caregivers

TO

EMAIL ADDRESS:

I HAVE SOMEONE WHO CAN HELP ME WITH THE INTERNET? YES NO

I WOULD LIKE TO COMMUNICATE USING THE INTERNET? YES NO

NIGHTIME PHONE: CAN CALL: YES NO CAN TEXT: YES N O

I HAVE ACCESS TO THE INTERNET? YES NO

IT'S OK TO TEXT TO ME ON MY CELL PHONE FROM: AM / PM AM / PM

DAYTIME PHONE: CAN CALL: YES NO CAN TEXT: YES N O

PERSONAL CONTACT INFORMATION

CELL PHONE NUMBER: I KNOW HOW TO TEXT ON MY CELL PHONE: YES NO

POA FOR FINANCE NAME: POA/FINANCE #:

POA FOR HEALTHCARE NAME: POA/HEALTHCARE #:

COMMENTS:

ALTERNATE CONTACT INFORMATION

I HAVE A CAREGIVER NAMED: CAREGIVERS PHONE #:

EMERGENCY CONTACT NAME: EMERGENCY CONTACT #:


INSURANCE INFORMATION

o Identifies all insurance in which patient is enrolled

o Easier to identify primary to verify coverage for CCM services

o Can identify if patient has secondary and if copay may be covered

OTHER COVERAGE: POLICY #:

COMMENTS:

PRIMARY INSURANCE: POLICY #:

SECONDARY INSURANCE: POLICY #:

PRESCRIPTION COVERAGE: POLICY #:

INSURANCE INFORMATION


I WANT THE PEOPLE WORKING WITH ME TO KNOW…

o Identifies if patient has any special personal needs

o Identifies barriers patient may experience that effect access to care

o Identifies areas in which patient may need added assistance or help

o Identifies if community resources/agencies need to be set up/utilized

o Identifies learning preferences for future education

o Identifies if advanced directives in place or further education needed

o Identifies legally appointed individuals so can collect paperwork

o Will help to populate the goals and interventions section

I LIVE: ALONE W/ FAMILY W/FRIEND OTHER

MOBILITY MY VISION OTHER

ENGLISH OTHER

READING

YES NOPLEASE

EXPLAIN:

DNR

COMMENTS:

I HAVE SPECIAL DIETARY NEEDS:

I HAVE THE FOLLOWING: POWER OF ATTORNEY

FOR HEALTH CARE

POWER OF ATTORNEY

FOR FINANCES ADVANCED DIRECTIVES

CERTAIN THINGS IMPACT MY HEALTH CARE: MY RELIGION/SPIRITUALITY NEEDS MEMORY AND/OR THINKING PROBLEMS

ACCESS TO CARE FINANCIAL ISSUES FAMILY ISSUES MY ABILITY TO COMMUNICATE

COMMENTS:

I LEARN BEST BY: SEEING PICTURES/VIDEOS BEING SPOKEN TO/TAPES OTHER WAYS

COMMENTS:

COMMENTS:

I HAVE CHALLENGES WITH: TRANSPORTATION MY HEARING

COMMENTS:

MY PRIMARY LANGUAGE IS: SPANISH/ESPANOL I NEED A TRANSLATOR

I WANT THE PEOPLE WORKING WITH ME TO KNOW…

W/ PARTNER OR SPOUSE IN ASSISTED LIVING


I HAVE CONCERNS ABOUT THE FOLLOWING…

o Identifies needed interventions for patient related to self-care/emotional

well-being

o Will generate goals and interventions to address each concern


o Allows care team to identify what education patient requires

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

MORE DETAILS/ COMMENTS:

MY ABILITY TO COPE WITH END OF LIFE ISSUES: I WOULD LIKE TO DISCUSS FURTHER

MY CURRENT DNR, POA, ADVANCED DIRECTIVES: I WOULD LIKE TO DISCUSS FURTHER

MY ABILITY TO AMBULATE/MOVE AROUND DAILY: I WOULD LIKE TO DISCUSS FURTHER

MY CURRENT EMOTIONAL WELL BEING/ ISSUES: I WOULD LIKE TO DISCUSS FURTHER

MY ABILITY TO MANAGE MY MEDICATIONS: I WOULD LIKE TO DISCUSS FURTHER

MY ABILITY TO OBTAIN HEALTHY FOOD TO EAT: I WOULD LIKE TO DISCUSS FURTHER

I HAVE CONCERNS ABOUT THE FOLLOWING…

MY ABILITY TO MANAGE MY CHRONIC CONDITIONS: I WOULD LIKE TO DISCUSS FURTHER

MY DECREASED ENERGY LEVEL / CHRONIC FATIGUE: I WOULD LIKE TO DISCUSS FURTHER

MY ABILITY TO CARE FOR/ CLEAN MY HOME: I WOULD LIKE TO DISCUSS FURTHER


RESOURCES AND ASSISSTANCE ASSESSMENT

o Identifies patient ability to care for self at home

o Identifies needed assistance for self-care, finances, daily supplies

o Care team can assess patient’s compliance with meds, doctor visits, ER

use

o Will generate goals and interventions to address each concern


o Allows care team to identify what education the patient requires

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

YES NO ADDRESS

I AM FREQUENTLY SAD AND AVOID OTHER PEOPLE? REFERRAL - ASSISTANCE

EDUCATION DONE

IT IS HARD FOR ME TO BATH/KEEP MYSELF CLEAN? REFERRAL - ASSISTANCE

EDUCATION DONE

SOMETIMES MY POWER OR UTILITIES GET SHUT OFF? REFERRAL - ASSISTANCE

EDUCATION DONE

SOMETIMES I AM UNABLE TO GET DRESSED IN AM? REFERRAL - ASSISTANCE

EDUCATION DONE

IT IS HARD FOR ME TO PREPARE FOOD FOR ME TO EAT? REFERRAL - ASSISTANCE

EDUCATION DONE

I FREQUENTLY MISS MY DOCTOR APPOINTMENTS? REFERRAL - ASSISTANCE

EDUCATION DONE

I ALWAYS CHOOSE TO GO TO THE ER WHEN I AM SICK? REFERRAL - ASSISTANCE

EDUCATION DONE

SOMETIMES I GO WITHOUT FOOD TO EAT AT HOME? REFERRAL - ASSISTANCE

EDUCATION DONE

RESOURCES AND ASSISTANCE ASSESSMENT

PLEASE ANSWER THE FOLLOWING QUESTIONS: STAFF USE ONLY

I FREQUENTLY FORGET TO TAKE MY MEDICATIONS? REFERRAL - ASSISTANCE

EDUCATION DONE


COMMUNITY RESOURCES AND ASSISTANCE AVAILABLE

o Provides resource tool to patient and family to access assistance from

agencies that are available within patient’s community or state

o Provides patient education on available help

o Shows documentation that education and resources were provided to

patient; supports utilization and shows patient refusal of assistance

PATIENT

REFUSED

COMMENTS:

MEDICAL NEEDS LOCAL URGENT CARE,

WALK IN CLINICS

TELEPHONE LIFELINE, LINKUP

SPIRITUAL LOCAL CHURCH DIRECTORY

MOBILITY / WALKINGLOCAL PHYSICAL THERAPY,

IN HOME THERAPY

SAFETY AT HOMELIFELINE SERVICES,

ALTERNATIVES FOR THE OLDER

EMOTIONAL DISTRESS

(COUNSELING)

BRIDGEWAY, ROBERT YOUNG,

LOCAL PSYCHOLOGIST

ASSISTANCE AT HOMELOCAL HOMECARE OR

HOMEMAKER SERVICE

MEALS OR DELIVERYMEALS ON WHEELS, SENIOR

CITIZEN CENTER

FINANCES / RENTLOCAL MEDICAID OFFICE,

H.U.D.

HOME REPAIRS AND

MAINTENANCEH.U.D. (DEPT OF HOUSING)

FOOD SUPPLIESLOCAL FOOD PANTRY,

S.N.A.P. (MEDICAID)

UTILITIES SALVATION ARMY

TRANSPORTATIONLOCAL COMPANIES, SENIOR

CITIZEN CENTER

ASSISTANCE FOR: SUGGESTIONSNAME OF AGENCY IN YOUR

AREAPHONE NUMBER

POWER:

ELECTRIC AND GAS

L.I.H.E.A.P., CURRENT POWER

SUPPLIER, H.A.R.R.P.

COMMUNITY RESOURCES AND ASSISTANCE AVAILABLESTAFF NEEDS TO FILL IN DESIGNATED AREAS WITH THE RESOURCES THAT ARE AVAILBLE FROM GOVERNMENT AGENCIES OR

FROM THE SURROUNDING COMMUNITY - UTILIZE FOR PATIENT IF TRIGGERED IN ASSESSMENT SECTION


THINGS I WANT TO IMPROVE OR CHANGE

o Allows patient to share problems and personal issues sometimes not

addressed, and how he or she has tried to manage them at home

o Items from this section should generate goals and interventions

o Allows care team to see patient’s personal perception of problems

o Allows care team to assess patient’s ability to manage self-care

o Encourages patient to be involved in setting up own personal care plan

MY PERSONAL GOALS AND INTERVENTIONS

o Patient and care team member will complete together

o Encourages patient to be involved in own care planning

o Will improve the level of patient involvement as patient will feel some

ownership

o Improves success as goals/interventions will be set to patient’s ability

o Should address any previous problems/concerns stated

IMPROVE/CHANGE: EXAMPLE: I WANT TO LOOSE 20 POUNDS BY THE END OF THE YEAR

WHAT I AM CURRENTLY DOING: I AM REDUCING MY PORTION SIZES AT MEALS, I NO LONGER BUY SUGARY SNACKS

IMPROVE/CHANGE:

WHAT I AM CURRENTLY DOING:

THINGS I WANT TO IMPROVE OR CHANGEINCLUDE ANYTHING THAT YOU WOULD IMPROVE OR CHANGE: CAN BE HEALTH ISSUES, DIET ISSUES, CERTAIN LAB RESULTS OR VITALS THAT ARE

ABNORMAL, EMOTIONAL ISSUES, DAILY LIFE ISSUES, ETC…

GOAL: DATE

COMPLETED(DESCRIBE &

START DATE)

INTERVENTION:

INTERVENTION:

INTERVENTION:

GOALS - THINGS YOU WISH TO WORK TOWARDS IMPROVING OR CHANGING

INTERVENTIONS - ACTIONS THAT HELP YOU ACHIEVE YOUR GOALS

MY PERSONAL GOALS AND INTERVENTIONS A HEALTH CARE TEAM MEMBER WILL WORK WITH YOU TO FILL OUT THIS SECTION.


GOALS FOR TESTS AND RESULTS

o Provides education to patient on required testing and healthy limits;

involves patient in discussing importance of testing

o Involves patient in self-care at home and motivates completion

o Encourages patient compliance due to structured goals (others are

watching)—care team can assess self-care ability

o Provides great resource tool for locating test results in one place

o Care team will refer to this section when making patient calls

o Will help to identify if further interventions are needed when goals are

missed

o Patient will feel accomplished when goals are met

HISTORY OF HEALTHCARE PROVIDERS

o Encourages patient to share a list of every provider he or she has seen

o Great resource for care team when reviewing past treatment history

o Allows one location to list referrals and providers seen going forward

DATE:RESULT/TEST

VALUE:DATE:

RESULT/TEST

VALUE:COMMENT COMMENT

GOALS FOR TESTS AND RESULTSRECORD ALL CURRENT HEALTH RESULTS/TESTS SUCH AS BLOOD SUGARS, HGA1C, WEIGHT, BP, CHOLESTEROL, ETC…

PROVIDE GOAL FOR EACH RESULT/TEST BEING MEASURED , INCLUDE REASON IF GOAL NOT REACHED IN COMMENT SECTION

RESULT/TEST BEING MEASURED: GOAL FOR RESULT/TEST:

HISTORY OF HEALTHCARE PROVIDERS

INCLUDE PHYSICIANS/PRACTITIONERS YOU HAVE SEEN IN PAST 5 YEARS FOR YOUR HEALTH NEEDS

PROVIDER NAME DATE LAST SEEN WHY DID YOU SEE THEM?


CURRENT HEALTHCARE PROVIDER/TEAM

o Identifies all care team members for patient/family members/caregivers

to avoid confusion

o Provides contact information to patient for ease of access to team

members

MY CHRONIC/LONG TERM DIAGNOSIS

o Allows patient to share diagnosis along with current problems; allows

assessment of patient’s understanding of disease

o Patient sharing problems allows staff to identify needed interventions

o Encourages patient to be involved in identifying care needs

HISTORY OF PROCEDURES / SURGERIES / HOSPITALIZATIONS / ER VISITS

o Resource tool to gather history

o Organized location for quick reference

o Allows for future documentation of these items

COMMENT S:

CARE COORDINAT OR

CURRENT HEALTHCARE PROVIDER/TEAM

PROVIDER/T EAM MEMBER ROLE PHONE # COMMENT S

CURRENT PROVIDER

DATE

DIAGNOSED

NEEDS

A TTENTION

MY CHRONIC/LONG TERM DIAGNOSIS

INCLUDE ALL CONDITIONS YOU HAVE BEEN DIAGNOSED WITH AND ARE MANAGING (PLACE AN "X" IN THE "NEEDS ATTENTION" BOX FOR

DIAGNOSIS THAT ARE CAUSING HEALTH RELATED PROBLEMS)

DIAGNOSIS CURRENT PROBLEMS EFFECTING HEALTH

DAT E HOSPITAL-

IZED?

HISTORY OF PROCEDURES / SURGERIES / HOSPITALIZATIONS / ER VISITS

DESCRIBE: PROC/SURG/HOSP/ ER EVENT COMPLICAT IONS / COMMENT S


ACTIVE MEDICATIONS LIST

o List of current medications is required resource tool for reference

o Can assess patient’s level of understanding of why he or she takes each

med and identify needed patient education

o Helps team identify over-the-counter medications patient is taking

o Identifies who ordered each medication when possible

o Provides baseline when addressing med lists and changes, moving

forward

MEDICATION ALLERGIES / INTOLERANCES

o Encourages patient to share all medication allergies and explain

reactions; helps care team assess patient’s level of understanding

o Allows team to identify level of allergic reaction to meds

o Allows team to identify medication intolerances instead of allergies

o Creates resource list for future care members and providers

DOSESTART

DATE

WHO

STARTED?NAME OF MEDICATION DIRECTIONS

WHY TAKE?

COMMENTS

ACTIVE MEDICATION LIST

INCLUDE ALL OVER THE COUNTER MEDICATIONS, SUPPLEMENTS, OR VITAMINS

DATE

OCCURRED

MARK AS

SEVERE

MEDICATION ALLERGIES / INTOLERANCES

PLEA SE LIST A NY MEDICA TIONS/OTC OR PRESCRIBED THA T YOU A RE A LLERGIC TO OR HA D A DV ERSE REA CTION TO

NAME OF MEDICATION REACTION TO MEDICATION / TREATMENT


ALLERGIES—NON-MEDICATION

o Identifies patient’s non-medication allergies that are not always

accounted for

o Identifies need for interventions or alterations to plan of care

o Educates team on items to avoid when giving patient care or treatment

IMMUNIZATIONS

o Supplies accurate list of past and current immunizations patient has

received; opportunity to provide education if needed

o Helps to avoid duplications

o Identifies patient compliance or need for interventions

DATE

OCCURRED

MARK AS

SEVERE

ALLERGIES - NON MEDICATION

INCLUDE ANY SUBSTANCE, FOOD, ETC THAT YOU HAVE ALLERGIC OR ADVERSE REACTIONS TO

NAME OF SUBSTANCE REACTION TO SUBSTANCE / TREATMENT

DATE

GIVEN

DATE

GIVEN

DATE

GIVEN

IMMUNIZATIONS

VACCINE NAME VACCINE NAME VACCINE NAME


HOW DO I / WHEN DO I?

o Provides patient education on 24/7 access care team

o Organizes access information for patient/family/caregiver (easier to

find when need to call)

o Educates patient/family/caregiver how to access patient portal or other

electronic system

o Opportunity to assess understanding of each item and need for

additional education/resource

o Section can be manipulated to add topics or adjusted to accommodate

the system used in practice setting

APPOINTMENT LOGS

o Organizes appointment history into one location for easier review

o Keeps patient/family/caregiver organized for future appointments

o Identifies why patient was referred to another healthcare provider

o Allows quick identification of referrals and associated new orders

OT HER NOT ES:

ACCESS THE PATIENT

PORTAL

PAT IENT PORT AL WEBSIT E ADDRESS:

LOGIN ID: (KEEP CONFIDENT IA L)

PASSWORD: (KEEP CONFIDENT IA L)

TALK TO MY CARE

COOORDINATOR?

CARE COORDINATORS NAME:NA ME:

CARE COORDINATORS PHONE #:PHONE #:

CARE COORDINATOR WILL CALL/TALK

WITH YOU ON:

DA Y/DA T E/T IME:

CARE COORDINATORS EMAIL:EMA IL:

COMMENTS:

HOW DO I - WHEN DO I?

GET AHOLD OF MY

PROVIDER (DOCTOR)?

DURING BUSINESS HOURS WHEN OFFICE OPEN:PHONE #:

AFTER HOURS WHEN OFFICE IS CLOSED:PHONE #:

DAT E:

APPOINTMENT LOGS

ENTER ALL APPOINTMENTS HERE, FILL OUT ALL COLUMNS EVEN IF SEEING SAME PROVIDER AGAIN

WHO SEEING: WHY SEEING: NEW ORDERS: COMMENT S


NOTES

o Open section for communication between care team and patient/

family/caregiver (miscellaneous use)

o Allows patient to make notes of items to discuss or remember for

future calls or visits

Gathering the above information is necessary so that the final care plan can encompass

all the needs of the patient, and not just one focused area. By understanding the purpose

of each care plan section, it will make the information gathering more efficient and

content worthy. Sometimes a patient does not prioritize problems appropriately. By

utilizing a comprehensive tool that pulls information from that patient, the care team will

be able to identify key areas where the patient may need added attention or assistance.

The goals of reviewing the care plan with the patient present are:

To note empty sections and missing information

To collect a complete comprehensive picture of the patient

To identify patient problem areas and/or concerns

To develop patient/staff goals and interventions with patient assistance

To identify patient/staff responsibilities in care moving forward

To educate the patient on available community resources

To set the patient up with needed services or assistance

To assess the patient’s level of understanding, self-involvement in care, and

education needed

If a care plan form is utilized, the next steps will be to transfer the information into an

electronic format. If a care plan was already started electronically, then a lot of the work

is probably finished in most of the sections. Some practice settings may require the care

plan to be completed at this point, and would refer to another section to incorporate

those final steps into the care plan process (See “7.6 Step 6: Complete Care Plan”).

KEY NOTE: The care team should establish a process outline identifying when each

step of the CCM process is expected to be completed. This provides a consistent

structure to all the team members, and will push for timely completion.

NOTE SECTION


KEY NOTE: The care team needs to set a date for the care plan to be reviewed, and

assign the member who is responsible for the review. Populating a workflow

calendar, or setting up electronic system reminders would be recommended.

7.3 Step 3: Review EHR Components (Mandatory)

This step is required per CMS regulations, and is one of the few EHR requirements for

CCM services. It is mandatory that certain information for each CCM patient is collected

by using a CMS certified EHR. Most established patients may already have the necessary

information loaded into the EHR, but many new patients may not. It is necessary to review

the following topics and make sure that all the necessary components are accounted for

while the patient is present:

(1) Patient demographics

(2) Medications

(3) List of all allergies

(4) Patient problem list

Most EHR’s will contain a large amount of content within each patient profile, but CMS

has currently only identified the items listed above as required. The EHR in use will need

to meet the CMS certification criteria established through December 31st of the previous

year. Currently, the EHR in use should be certified to the CMS 2014 editions of certification

criteria. As we move forward in time, CMS may require updated certification criteria.

Because of CMS updates and evolving regulations, it will be important to check for the

current requirements for the EHR a practice is utilizing. This can be checked by visiting:


7.4 Step 4: Set Up Calendar

Every patient will be involved in the CCM program at different levels of participation. To

encourage the optimal level of commitment from patients, it is important to adjust the

service elements to meet the needs of each patient individually. The care team member

needs to work with the patient, either in person or by phone, to identify what dates will

work for these items.

Monthly CCM phone calls to the patient:

o Patient should decide what day and time these calls will occur.

o Add day and time to patient calendar and care team calendar.



o Make sure patient’s correct phone number is recorded.

Future patient appointments:

o Review future needed appointments with patient identify dates.

o Have appointments entered onto system calendar.

o Provide documentation to patient with appointment dates and times.

o Make sure all appointments are scheduled with same provider.

o Set up patient appointment reminders in patient portal or other tool (if

applicable).

Make sure the dates and times that are designated are ones the patient decides will work

the best for his or her schedule. This will increase the patient’s level of compliance and

interaction with the CCM program and the care team members. Reaching out to the

patient with appointment reminders will help to avoid missed visits, and can motivate the

patient to keep the scheduled visit.

7.5 Step 5: Finish Setup

Once the patient leaves or is no longer on the phone, it is important to go back through

the work that has been done to complete any unfinished items from the setup process.

This can be different for each practice setting depending on the systems and tools being

used. Here is a list of items that would need attention if not already completed.

Finish setup in patient portal, electronic system, or other.

o Set up patient engagement tools in system (if applicable).

o Set up any patient reminders, such as appointments, phone calls, etc. (if

applicable).

o Set up staff reminders or work tasks (if applicable).

Make sure all spreadsheets/tools used for patient are completed with

necessary info.

o Add patient’s name to any tracking forms that will be used.

o If using a central “Active CCM Patient List”, add patient to list.

Should be accessible by all members of practice setting.

Include all assigned providers and care team members on list.

Allow access by scheduling for future appointments.

Make sure that any information to be mailed to the patient is prepared

and sent.


o Suggest making a running list to be mailed out all at once when

finished with setup.

Update other care team members about the new enrollment.

Include any pertinent care details that are unique for that patient.

7.6 Step 6: Complete Care Plan

This step can vary greatly depending on the process the care team utilizes. No matter the

process, the goal is to make sure that a thorough patient-centered care plan is completed.

If the care plan is already finished, then this will just be a quick review. Make sure the

following items have been addressed:

IF A PAPER CARE PLAN WAS UTILIZED

o Make sure all sections are complete.

o Review with assigned provider for final approval.

o Transfer information into electronic system.

o Print final copy.

Mail/send final copy to patient (if do not already have).

Upload copy into EHR.

o Make sure care team is aware care plan is done and knows how to

access.

o Send/forward/email copies to other providers/practitioners who may

be involved with patient (may also grant access if system allows):

Referral providers or settings; and

On-call providers or settings, including contracted parties (if

applicable).

o Record time taken to complete these activities.

IF AN ELECTRONIC CARE PLAN WAS UTILIZED

o Review care plan information to make sure all sections are complete.

o Review with assigned provider for final approval/electronic signature (if

possible).

o Print a copy / send a copy to patient (if do not already have).

o Make sure copy, if not built inside EHR, is uploaded into EHR.

o Make sure care team is aware final care plan is done and can access.

o Send/forward/email copies to other providers/practitioners who may

be involved with patient (may also grant access if system allows):


Referral providers or settings; and

On-call providers or settings, including contracted parties (if

applicable).

o Record time taken to complete these activities.

7.7 Step 7: Final Review

It is important to always have a process in place that allows for a final review of the work

that has been done. The final review is the last step that allows a care team member to

comb through the initial CCM setup process, and make sure that important elements have

not been skipped. Utilizing a simple checklist is one way to provide a structured look back

through that process. A care team can decide to use whatever tool fits for that practice

setting. ICAHN – IRCCO has a checklist tool available if included with the manual (See

ICAHN – IRCCO CCM tool: “PATIENT READY TO PARTICIPATE”).

TIME FOR A SHORT BREAK

Ok…take a big deep breath and say to yourself “I HATE CCM MANUALS!”

Was that a smile?!

You have read through a lot of information and you are handling it like a

trooper. It may seem a little overwhelming…BUT…it will all make sense once

you process your first couple of patients. Go grab a quick snack…throw a dart

at the picture of whoever put you in charge of CCM…and let’s keep going.


CHAPTER 8 TIME TO BEGIN CCM SERVICES

To be at this point and reading this section, means a lot of work has been accomplished.

The patient has gone through the initial CCM setup process, the CCM care team has

organized all the required information, and both are prepared to move forward with

monthly CCM services. Care team members should be knowledgeable about the previous

information, and should be ready to begin reaching out to the CCM patients. This chapter

will help the care team members to understand CCM activities, and how to accumulate

those necessary 20 minutes or more of non-face-to-face time each month.

8.1 What Activities Can Be Counted in Those 20 Minutes?

Monthly billing for CCM services cannot take place until 20 minutes of non-face-to-face

activities have been performed by the care team. It is important for the care team to

understand what activities can be counted that involve the patient, and what activities can

be counted that do not involve the patient. To help avoid confusion, the care team should

populate a reference list of the different acceptable activities that can be performed by

each care team member.

KEY NOTE: If the activity is only being performed by the patient and does not involve

the clinical staff/care team, then it cannot count toward the 20 minutes of non-face-

to-face time. In order to count, all activities must involve clinical staff/care team

time, not patient time.

For example: An electronic system sends messages to the patient. The patient

reads the messages, follows prompts, answers questions, and inputs data

when asked. The above activities are patient activities, and do not involve the

clinical staff/care team. None of the time for these activities can be counted

in the monthly 20-minute total.

KEY NOTE: Sometimes the activities that the clinical staff/care team perform do not

involve talking with the patient on the phone. Provided the clinical staff/care team

is performing activities that directly affect the CCM patient’s plan of care, that time

can be counted in the monthly 20-minute total.

For example: In the above scenario, the patient adds information into the

electronic system which can then be accessed by the clinical staff/care team.

They will spend time reviewing the information, updating the provider, and


altering the patient’s plan of care if necessary. The activities which involve

the clinical staff/care team, and do not include the patient, can be counted in

the monthly 20-minute total.

The following is a list of acceptable activities that a care team can perform during CCM

services. It is not considered an all-inclusive list, but should give guidance toward

understanding what activities can be counted each month. The information is a blend of

identified CMS activities, as well as activities outlined in the current AMA 2017

Professional CPT Manual. Together, the list outlines the majority of typical clinical

staff/care team activities that can be counted in monthly CCM services.

Communication/engagement regarding all aspects of the patient’s care

and necessary treatments (all physical, mental, social aspects): o With patient o With patient’s family members, guardian, caretaker, or surrogate

decision makers o With any provider(s) involved in patient’s care o With other healthcare settings (hospital, ER, assisted living, etc.) o With community resources or agencies (and their staff) o With other care team members who are collaborating to find solutions o During any form of care transition or referral

Monitor/request/review/assess any information pertaining to a CCM

patient which is necessary to provide an optimal treatment plan:

o Requesting data/results (weights, blood sugars, BP, labs, tests, logs,

health information, etc.) from patient, providers, healthcare settings, and

care transitions

Reviewing all data/results and assessing for needed interventions

Sharing data/results with main provider (other providers prn)

o Requesting discharge instructions and notes after referral visits

o Reviewing interactions/answers patient provided within questionnaires

(electronic systems, portals, emails, etc.)

Evaluating information; assessing for needed interventions

and/or patient education

Updating provider with concerns or abnormal findings

o Assessing patient’s compliance to treatment plan; identifying abnormal

findings and reporting to provider


o Assessing patient’s knowledge level and identifying education needs

Communication/engagement with home health agencies and other

community services that are utilized by the patient: o Identifying available community and health resources for patient;

educating patient on what is available and why it’s needed o Setting up services/referrals when necessary o Collaborating with services when possible to identify current patient

condition changes, concerns, new orders, etc. o Reviewing information to ensure patient receiving all recommended

preventative services o Updating provider on services progress, concerns, requests

Monitor the patient’s ability to manage self-care and provide education/

support/interventions to the patient/family/caregiver to support self-

management, independent living, and activities of daily living: o Assessing patient during interactions for self-management of

medications and self-care in home setting o Interpreting information to determine if patient’s needs are being met

Updating provider with identified concerns Altering care plan to address self-care interventions/goals as they

change or when new ones are needed Educating patient/family with new concern, orders, interventions

o Scheduling patient appointment when face-to-face visit is warranted o Providing referrals to community resources if needed, such as home

health care, meal delivery, etc.

Setting up access to community services when available (DM

classes, nutritionist, support groups, etc.) o Assessing patient utilization of all resources put into place

Assessment/support/education for compliance: o Assessing medication use; identifying need for intervention o Educating patient on medications, treatments, diagnosis o Reviewing care plan alone, or with patient, to assess how patient is

following identified goals; providing education for patient as needed o Providing necessary resources when patient unable to meet compliance

without assistance


o Reviewing discharge instructions, medication lists, new orders with

patient to assess if understanding and following them correctly o Medication reconciliation with new orders and care transitions (unless

part of TCM); provide education Management of care transitions not reported as part of Transitional Care

Management: o Facilitating communication among all healthcare settings o Preparing any care transition documents o Communicating patient needs to other healthcare providers o Reviewing discharge instructions and care transition paperwork

Reviewing with patient to assess compliance/understanding Providing education to patient regarding new orders/meds Reviewing with provider to identify changes in care Reviewing to identify concerns or needed interventions

Development, communication, and maintenance of a comprehensive care

plan and related tools: o Monitoring patient progress and adherence to care plan goals o Reviewing care plan with patient as needed to discuss progress o Assessing for needed care plan revisions based on goals met o Updating care plan with plan of care changes, new diagnoses, new

medications, condition changes, care transitions, etc. o Updating provider on care plan as needed—collaboration o Updating ancillary paperwork, charts, spreadsheets when needed

Remember that the above list is not considered all inclusive, as there may be other

activities that are also acceptable under CMS regulations. This list will also transform as

practice settings implement patient portals and other electronic technologies within their

CCM program structure. No matter how the 20 minutes of time is accumulated, it is

important to remember a few key items:

Time counted in the monthly CCM total CANNOT be counted anywhere

else.

Example: A patient comes in for an appointment with the provider, and the

care coordinator steps into the room with the patient to discuss CCM. The

time with the patient will count toward the patient visit and not CCM services.


To be counted in CCM services, the patient will need to complete the visit

with the provider, and then separately meet with the care coordinator.

Face-to-face time can be counted.

Not every minute of activity with the patient must be non-face-to-face, but

the majority of them typically will be. The example above shows that there are

times when the patient may be in the office, and the care coordinator may

spend some time with him or her face-to-face.

Any member of the clinical staff/care team’s time can be counted.

o This includes the provider, if the time provider spends with patient

meets the activity guidelines, and is not counted anywhere else.

o Some practice settings will have a variety of members included in the

clinical staff list. Follow the CPT definition of “clinical staff” (See “2.1

Assemble a Care Team”) to determine whether a particular member’s

time can be counted.

Other things to consider:

20 minutes of non-face-to-face time is the minimum amount required. More

complex conditions will prompt increased accumulation of minutes and may

warrant billing for Complex CCM services, if available to practice type.

CMS does not allow minutes to be rounded up to meet the minimum 20

minutes.

o Actual activity times must be logged and counted as documented.

o If logged minutes only reach 19 total minutes, CCM services cannot be

billed for that calendar month.

Minutes from one month cannot be added with another month’s total minutes.

o If a practice setting does not bill for CCM services one month, those

minutes are lost and cannot be counted with the next month’s minutes.

o Two months’ minutes cannot be combined to reach the 20 minutes;

minutes are separately counted each calendar month.

8.2 CCM Services Per Calendar Month

When providing CCM services for multiple patients, it is necessary to have a structured

process in place. It should be clear to all care team members what process is to be

followed, and what forms and tools are to be utilized. If a care coordinator has been

assigned to oversee the CCM program, he or she should make sure that all care team


members are fully educated on every CCM service element before moving forward. Now

it is time to bring all the information together to implement a successful CCM program.

The following elements should be accomplished each calendar month that CCM services

are provided and billed for a patient:

20 or more minutes of non-face-to-face time is performed by clinical staff.

Provider is updated on CCM patient’s progress, concerns, or interventions

needed.

All spreadsheets, logs, calendars, etc. are completed and up to date.

Care plan remains up to date with changes in treatments for patient.

Care transition process is followed (if needed) with use of CCD.

All documentation is up to date in patient’s medical record to reflect services.

Patient is engaged in CCM services.

Billing notified to invoice for all CCM patients with claims sent for processing.

The services that comprise monthly CCM will vary for each patient that participates. One

patient may need more attention to medication compliance, while a different patient may

need education on diet and diabetic needs. No matter what requirements the patient may

have, the care plan should reflect each need clearly. The care plan will aid the care team

in determining what activities and education should be provided to the patient each

month. It will also help determine what interactive programs should be loaded into any

electronic system that is being utilized. As the patient evolves through the process, the

care plan should evolve with him or her.

8.3 How to Motivate Your Patient

The key to a successful CCM program is a motivated patient. Motivation pushes a patient

to become involved in his or her own self-care management, to make changes that will

impact quality of life, and to maintain any success achieved along the way. But how do

we get a patient to become motivated?

Motivational Interviewing

Motivational interviewing (MI) was first conceptualized by clinical psychologist Professor

William R. Miller, Ph.D. in 1983, and then further developed into clinical procedures in

1991 by Miller and co-founding Professor Stephen Rollnick, Ph.D. (Motivational

Interviewing: Preparing People for Change , Miller and Rollnick, 1991)( Motivational

Interviewing in Health Care, Rollnick, Miller & Butler, 2008).

http://www.amazon.co.uk/Motivational-Interviewing-Third-Edition-Applications/dp/1609182278/


http://www.amazon.co.uk/Motivational-Interviewing-Health-Care-Applications/dp/1593856121



MI is a skillful form of collaborative conversation between the caregiver and patient. The

goal of this style is to help the patient self-reflect and develop internal motivations to

make changes that will affect the patient’s health. The care team member cannot force

the patient to become motivated; the patient must be internally committed to wanting

change to happen. This internal motivation will allow the patient to work toward the

health goals that have been established in the patient-centered care plan.

There are volumes of available information directed at understanding and learning the

principles surrounding MI. The purpose of this section is to identify the main principles,

and the skills necessary to achieve a successful MI session. A care team member engaging

in MI will want to understand the following:

Ambivalence is normal.

o Patients are resistance to change; they are very attached to their

behaviors.

o Be accepting of patient’s ambivalence—acceptance facilitates change.

o Remember to express acceptance not agreement:

“I understand why you chose to eat the cake.”

NOT

“It is ok that you chose to eat the cake.”

o Emphasize patient’s control over choices:

“It is your choice to proceed or not.”

OR

“The decision is yours to make.”

Always utilize skillful and reflective listening skills.

o Allow patient to lead the conversation and summarize what patient said

back to him or her.

Acknowledge what you hear, even if you do not agree with it.

Shows patient you understand and are listening.

o Use reflective statements:

“You are saying that you. . .?"

“So, you feel...”, “It sounds like you...”, “You're wondering if...”

"What I hear you saying is that you feel . . . and you want. . ."

o Express empathy—be attentive and nonjudgmental:

“This is really important to you.”

“I understand…”


Do not use negative labeling words like “non-compliant”.

Resist fixing.

o Do not give advice, make suggestions, provide solutions.

Patient can find solutions to problems with your guidance.

Ask open ended questions: “What do you think about…?”

o Provide information and education in a neutral manner.

Do not impose your perceptions onto patient.

Allow patient to form own interpretation and voice solutions.

o Avoid trying to persuade patient with your logic or through lecturing.

o Bribing patient emotionally does not promote self-motivation.

o Patient states, “The cake I ate for dinner probably made my blood sugar

high.”

Care member replies, “You think the cake had an effect on your

blood sugar?”

Care member resists making judgement about the inappropriate

food choice and counseling patient, instead promoting self-

reflection and validating what patient said.

Patient encouraged to speak freely, form a conclusion on own,

and learn from it.

Avoid arguments and confrontation.

o Arguing/confronting does not motivate patients.

o It weakens the rapport between care team and patient.

o Recognize if patient shows resistant behaviors:

Ignoring—not answering or responding to you, inattentive;

Interrupting—cutting you off or talking over you;

Denial—makes excuses, blames others, disagrees, pessimistic; or

Anger—argumentative, hostile, challenging remarks.

o Resistance from patient indicates new direction needed.

Patient not ready for change indicated for current goal; switch

to different goal.

Care member may have misunderstood patient; ask patient to

explain.

Recognize signs of patient motivation.

o Patient will identify goals and ideas on how to change without

resistance.


o Motivation toward change indicates patient involved in self-care.

o Create a discrepancy to further patient’s motivation.

Make sure patient aware of consequences related to behaviors.

Ask patient, “What’s good about this behavior?”, “What is

not-so-good about this behavior?”

Forces patient to realize behavior is not promoting goals.

Have patient identify what should change, he or she

needs to hear own voice say this out loud.

The relationship between the care team member and the CCM patient is crucial to success.

Building a good rapport begins with the first conversation the care team member has with

that patient. MI is a useful skill that will help care team members communicate effectively

and therapeutically during each patient interaction. As the patient’s trust for the care

member increases, so will the patient’s level of self-motivation and involvement.

The above information provides a quick overview of the key elements within MI. For

further or more in-depth information, the care team may choose to access the original

sources of MI:

Motivational Interviewing: Preparing People for Change (Miller and Rollnick,

1991; 2001 & 2012)

Health Behavior Change: A Guide for Practitioners (Rollnick, Mason & Butler,

1999)

Motivational Interviewing in Health Care (Rollnick, Miller & Butler, 2008)

8.4 Reaching Out to Each Patient

Typically, most activities will center around calling the patient to discuss how he or she is

feeling, review how self-care elements are going, and address any changes in the patient’s

current condition. A care team member should always review each CCM patient’s

information before initiating contact, and keep it available for easy reference during the

conversation. The following outline demonstrates how a telephone call to a CCM patient

may go:

Care team member Mary reviews patient’s care plan: Mr. Jones has CHF/ DM II;

begins tracking time a 0958am.

Mary calls Mr. Jones at agreed upon time: July 10th at 10am.

Mr. Jones answers and recognizes Mary, with whom he consistently speaks.


http://www.amazon.co.uk/Health-Behavior-Change-Pip-Mason/dp/0702031534



Mary asks Mr. Jones several questions: how he is doing today, has he weighed

himself today, how have his blood sugar results been, and has he noticed any

changes in his health.

Mr. Jones shares his weight, his blood sugar log results (all are within acceptable

range), and he also shares that the last day or so he has been a little short of

breath.

Mary reviews Mr. Jones’s information from the last month and notices he has

gained 5 lbs., and his blood sugars are typical to previous results.

Mary asks Mr. Jones more questions due to complaints of SOB and weight gain:

does he have any weights from the previous days, and does he have any

swelling that is new.

Mr. Jones shares weight from the previous 4 days as he weighs himself daily,

and that his fingers and ankles are “puffy” today.

Mary identifies that Mr. Jones has gained 3 lbs. in 2 days.

Mary asks Mr. Jones to pull out his medications to review what he is currently

taking.

Upon med review it is noted that Mr. Jones is on a diuretic and is taking it as

prescribed. Mr. Jones is able to identify the med and state the reason for taking

it. Mary praises Mr. Jones for involvement and knowledge of his own care.

Mary asks Mr. Jones to recall his last several meals for the past couple of days.

Mr. Jones runs through many items that are appropriate for his diet showing

that they are well balanced and nutritious.

Mr. Jones then adds that he has been trying to eat more almonds recently

because he read that they are good for his prostate.

Mary compliments Mr. Jones for being conscious of other healthy habits and

agrees that almonds can be great, but Mary questions the type of almonds he

is consuming.

After discussion, Mary determines the almonds are highly salted and Mr. Jones

did not identify this because they were labeled as “smoked almonds”.

Mary then lets Mr. Jones know that his weight gain and his SOB may be

attributed to the almonds, but would like him to see the provider that day, just

to make sure something else is not going on.

Mr. Jones agrees and an appointment is scheduled for 2pm that afternoon.

Mary then follows up with the provider to discuss her findings. The provider

agrees with her observation and is happy the appointment is scheduled.


Mary charts pertinent discussion points in Mr. Jones’s medical record, and she

then stops her time tracking; it has been 9 minutes and 38 seconds.

Mary logs her activity and the time onto the CCM activity log for Mr. Jones.

The next example shows how a care team member may choose to interact with a CCM

patient when an electronic system is being utilized. It is important to understand how the

activities differ, and when certain activities cannot be counted in the monthly 20-minute

total.

Mrs. Smith is an 85-year-old female with chronic DM II, and COPD. She lives

alone with no caregiver, so she is responsible for her own care. Mrs. Smith has

identified that she frequently forgets to check her blood sugars, and is not

always able to cook big healthy meals. She has shared that she sometimes

remembers her inhalers, but can get them confused with each other. Mrs. Smith

is enrolled in the CCM program, and has been loaded into the patient portal

system. She has agreed to receive emails from the patient portal, and has a

computer available at home that she uses frequently. The following activities

are typical non-face-to-face services that can be set up and completed for Mrs.

Smith:

o Care team member loads various information into patient portal/

electronic system that will be sent out to Mrs. Smith, focusing on COPD

and DM II.

o Mrs. Smith opens computer at home to see new message has arrived

from patient portal program, and opens the message to see what it

says.

Message reminds patient to check blood sugar and report

result in system.

Message provides interactive education on DM II and COPD

along with Q&A portion; some questions request patient to

input answers.

o Mrs. Smith completes all items, inputs blood sugar, and answers

Q&A sections.

o Care member checks patient portal to see if Mrs. Smith has responded

to message sent, and locates the results and answers that patient

inputted.

Care member reviews blood sugar results and answers to Q&A.


Care member identifies problem areas and concerns that may

need interventions based on answers Mrs. Smith gave.

o Care member calls Mrs. Smith to review the information she provided

in patient portal and assess patient’s level of self-care management.

Discusses high blood sugar result and how other results have

been.

Discusses diet and choices; recommends meal sizes to meet daily

needs.

Reviews current medications and inhalers and how she is taking

them.

o Care member validates that problem areas do exist and acknowledges

concerns about Mrs. Smith’s ability to manage portions of her own care.

Mrs. Smith still mixing up inhalers, blood sugar results a little high,

and current diet showing poor choices and inadequate portions.

Mrs. Smith’s answers are not consistently correct and she is

sometimes confused—at one point becoming teary and stating,

“I wish there was a way for this to be easier”.

o Care member consoles Mrs. Smith and tells her they will call back after

speaking with provider about how she is doing.

o Care member consults with provider and updates on concerns identified.

Together they identify Mrs. Smith’s need for meal assistance, diet

education, inhaler education, and medication setup.

They agree that Mrs. Smith needs interventions in the home

setting; provider states recommendations.

Can set up a meal delivery if available in area.

Can set up patient with diabetic educator classes.

Set up referral for home healthcare services.

Reach out to Mrs. Smith’s family to see what help they can

provide.

o Care member reviews Mrs. Smith’s medical record to see if consent given

to talk with family members and to whom.

Care member calls family with update and to see if assistance is

possible.


Daughter agrees to pop in every a.m. to do medication oversight,

will label inhalers to avoid confusion, and will make sure patient

has breakfast.

o Care member calls Mrs. Smith back.

Updates patient on provider’s recommendations and daughter’s

assistance.

Patient agrees to all needed interventions.

Care member asks patient’s choice for home healthcare and

provides education about services that will be set up.

o Care member sets up home healthcare referral, meal delivery, diabetic

educator classes.

o Care member loads patient portal with inhaler education, diet

education, reminders for class times, and overall self-care information

(if available). May also opt to mail education materials to patient and

family members.

o Care member documents all events in Mrs. Smith’s medical record,

updates care plan to accommodate new services, adds reminders on

calendars.

o Care member tracks time, adds activities onto tracking log with total

time.

The above example is for learning purposes, and not the only course of actions available.

When the care team member is tracking activity minutes, it is important to be able to

identify which activities are care team (clinical staff) time and which are patient time. CMS

regulations clearly state that only care team (clinical staff) or provider time may be

counted in the monthly accumulation of 20 minutes. That means that the time for patient-

only activities above would not be included when tracking minutes (Patient time only

activities have been made bold and underlined above).

KEY NOTE: A care team's goal is to reduce health exacerbations through patient

compliance, patient education, and patient involvement in self-care management.

There may be instances where a referral to a home health agency may become

necessary. The care team will always want to collaborate with community resources

to increase the quality of care that the patient receives. If the patient qualifies and

is enrolled in home healthcare, the practice setting will need to be aware of the

following:


The provider will continue to follow the patient’s care once enrolled in

home healthcare services.

The care team should collaborate with home healthcare agency staff to

remain up to date on the patient’s condition and update the care plan as

needed.

All CCM services should continue.

Home healthcare agency time cannot be counted in the monthly 20

minutes.

Home healthcare supervision code (G0181) available for provider billing.

o Code definition (See “9.2 When Is It NOT Okay to Bill for CCM?”).

o Refers to provider activities, not home healthcare services.

CCM and G0181 cannot be billed for the same provider within the same

calendar month.

o Patient can be enrolled in both CCM and home healthcare, but

would need to decide which service code (CCM or G0181) would be

used for billing.

o CCM and G0181 encompass similar activities, and billing for both

by same provider would be double dipping.

The exact same parameters would apply to hospice care supervision

(G0182) which mimics the G0181definition, but is for hospice services.

As the care team moves forward, it is important to have a tool that will help to keep track

of the activities performed, and the time it takes to complete them. Each activity will not

always take the same amount of time as you interact with different patients. CMS does

not allow for minutes to be rounded up, so it is necessary to be as accurate as possible

with the time that is documented. Some patients may be more complex, and would

benefit from more calls during the calendar month. Other patients, who are more stable

and involved in self-care management, may only need one phone call per month.

Once the care team reaches the 20 needed minutes (or more if doing complex services)

for a CCM patient, the billing department can be notified that CCM services are complete

and ready to be billed (See “9.1 Communication Process”). It would be beneficial to

develop a standard process, as it can become time consuming if billing is contacted each

day, and the possibilities for errors increase with scattered information. A better solution

would be to keep a running list of patients to be submitted to billing at the end of each

calendar month, allowing for all CCM claims to be made at one time. This process can


help avoid denials, since the service period for CCM is the 1st through the 30-31st of each

month. Submitting a claim prior to the end of the month can cause conflict with dates. A

practice setting will need to decide what process fits the needs of the care team and billing

staff.

KEY NOTE: What is the meaning of “calendar month”? For the purposes of CCM

services, a calendar month is the 1st thru 30-31st of any month, and is the time frame

during which CCM service minutes can be counted together. A month is not

identified by the number of days, but by the name of the month. For example:

January 1st thru January 31st is an acceptable calendar month for CCM, but January

15th thru February 14th is not.

There is no limit to how long a patient can receive CCM services. Provided that the

mandatory guidelines where followed for enrollment, the patient can receive CCM for his

or her lifetime. Also, a new consent does not have to be completed if the services are

provided under the same billing practitioner throughout the entire service period.

Some months, the 20 minutes of non-face-to-face time may not be completed for all CCM

patients. This is ok, as CMS does not mandate that CCM services must be billed every

month for every patient. The practice setting would simply not bill CCM services for that

patient that calendar month. CCM services should continue for the patient, and billing

would commence the following calendar month if the 20 minutes were achieved.

8.5 Transitions in Care

At the beginning of the manual (See “1.5 Process for Transitions in Care”), it was

identified that a practice setting providing CCM services will need to have a process in

place to handle a patient’s care transitions. The purpose of this process is to increase

communication and collaboration between all healthcare providers involved in the

patient’s care. CMS has not mandated what the structure of this process must follow, only

that the process must include a “Continuity of Care Document” (CCD) that is shared in a

“timely” manner. An effective transition process should include and/or achieve the

following points.

Education for the patient about the transition process the care team will follow:

o Include what would constitute a transition.


o Inform patient what information will be shared with other healthcare

providers.

o Provide explanations as to why this process is important.

o Identify patient’s responsibilities in the process.

o Encourage patient to inform care team if part of the process is missed.

Communication with the other healthcare provider involved in the transition of

care:

o Provide the CCD (See below “What should be included in the CCD?”)

to healthcare provider or healthcare setting patient transitioning to the

Healthcare provider to which patient is referred,

New healthcare setting (assisted Living, NH, etc.) to which

patient moves,

Admitting unit in hospital setting to which patient is admitted,

ER staff/providers when patient visits ER (when possible), and

New provider to which patient transfers care.

o Make sure new healthcare provider/setting has all the current

information about patient, so that all needs are addressed, and errors

can be avoided.

o Obtain information from healthcare providers after transitions including

Consultation notes and recommendations,

Discharge instructions,

Any labs or testing results, and

New or changed orders.

Collaboration between CCM provider and other healthcare providers:

o All healthcare providers should communicate and work together to

provide the optimal treatment plan to CCM patients.

o CCM provider adjusts patient plan of care to accommodate new orders

or recommendations from other healthcare providers.

Share the required CCD with other healthcare providers in a “timely” manner:

o CMS does not define “timely”, but should be shared within a reasonable

amount of time that allows for the optimal treatment of that patient.

o Can share through EHR, secure email, secure faxing, or solution of

choice.


The care team members need to formalize a structured transition process that will be

followed for all CCM patients. It is also suggested that the same process would benefit all

patients within the practice setting, and not just the CCM patients. By utilizing a process

across all patient types, it would minimize confusion in daily care delivery, while increasing

quality outcomes for everyone. Once the care team decides how the transition process

will be structured, it will be helpful to formalize the plan on paper. Also, remember to

designate a care team member to each step of the transition process. This will decrease

confusion and avoid unnecessary duplications.

What should be included in the CCD?

CMS mandates that a CCD, formerly referred to as the “clinical summary”, is created for a

CCM patient each time a transition in care takes place. The CCD is then shared with the

healthcare provider or healthcare setting the CCM patient attends. CMS has stated that

the CCD needs to provide a clinical summary of the current care and treatments that the

CCM patient would require. This is a broad statement, and could be interpreted to include

a vast amount of information. Various resources from CMS have listed some of the

following key elements that should be included in the CCD:

Patient demographics

Complete and current patient medication list

Complete and current patient list of allergies (medication, food, other)

Current patient problem list

Summary of current treatment the patient is receiving

Summary of current focus problems and interventions

Summary of care that would allow the healthcare provider to visualize a full

picture of the patient’s needs

Copy of the up-to-date patient care plan (this would satisfy many of the

above elements)

CMS did not mandate how the CCD should be formatted, or how it should be created. If

a practice setting utilizes an EHR, creating a CCD should be a simple process depending

on the system. But if a practice setting does not have the ability to create the CCD through

electronic measures, then it is okay to create the CCD by hand. The goal of the CCD is to

ensure that the receiving healthcare provider/healthcare setting obtains an accurate

summary of all the needs of the patient for whom they are going to provide care.


CHAPTER 9 BILLING PARAMETERS

Billing for patient services can be diverse as you scan across different service lines and

settings. It is always important to make sure that your billing staff is fully knowledgeable

about the current regulations that pertain to your particular practice setting. The

information provided in this section should be considered a helpful tool to guide billing

staff through the CCM services billing process. If a practice setting has any concerns or

questions about billing for CCM, they should always consult with any governing

regulatory bodies for clarification.

At this point, it should have already been determined that the practice setting is eligible

to bill for CCM services. A quick review can be performed to make sure key billing barriers

have not been missed:

The practice does not already participate in a CMS sponsored model or

demonstration program that includes payment for CCM services (such as

MAPCP or CPCI). The practice cannot bill for patients attributed to one of these

programs, but can bill for patients not attributed.

The CCM program will be provided under a qualifying physician/practitioner as

stated by CMS regulations (See “1. WHO CAN PARTICIPATE?”).

Any billing concerns have been reviewed with appropriate governing bodies

MAC provider, CMS, FI, other), and answers received.

Once all possible barriers have been identified and resolved, it is time to move forward

through the billing process.

9.1 Communication Process

As CCM services are completed each calendar month, the billing department will need to

be notified when it is okay to bill for each CCM patient. The care team and billing should

work together to develop a standard process that is both efficient and organized. The

process should cover a calendar month and should outline all of the following steps:

How the care team will track minutes for each CCM patient.

Where the care team will list patients when they have completed the 20 minutes

of CCM services.

When and how a list of patients will be given to billing department.

List should contain the assigned provider for each CCM patient.


Method for billing to identify when a patient should be billed for complex

CCM (more minutes).

Identify date that billing will submit claims for all CCM patients.

Billing should have identified NPI/TIN numbers to be used consistently for each

patient.

Method for billing to communicate back to the care team that billing for CCM

was completed.

It is not recommended to notify billing every day. This can be time consuming, and

increases the possibility of errors due to information becoming lost. A better solution

would be for the care team to keep a running list of patients that have completed CCM

services. The care team can submit the list to billing on a designated day of each calendar

month. It is suggested to give the list of patients to billing at the end of each calendar

month, and then billing will submit claims for all CCM patients at one time. This process

can help to avoid missed patients, and to avoid potential denials (Service period for CCM

is the 1st through the 30-31st of each month; submitting claims prior to the 30-31st can

cause conflict with dates).

This process can be developed individually for each practice setting, so that staff needs

can be accommodated. A simple spread sheet can be developed that allows for the above

information to be tracked. If the spread sheet is developed electronically, it can be easily

updated and accessed by all staff members within the clinic. Make sure the care team and

billing are educated on the how to use the tool, and how the tool will be accessed.

9.2 When Is It NOT Okay to Bill for CCM?

A practice setting needs to quickly establish the requirements needed to bill for CCM

services, as well as when billing is not permissible. CMS has identified certain settings or

situations when CCM services are not eligible for reimbursement. The following are some

of the types of situations that have been identified as ineligible for CCM services billing.

The patient is in a skilled setting, receiving Part A Medicare benefits.

The patient is an inpatient in hospital, receiving Medicare benefits.

The patient is in a service period for home health care supervision (G0181)

or hospice care supervision (G0182).


o Definition—Provider supervision of a patient receiving complex and/or

multidisciplinary care modalities in homecare/hospice that include a

regular physician:

Development/revision of care plans,

Review of patient status,

Review of related labs/tests,

Communication with outside health providers involved in

patient’s care,

Adjustment of medical treatment plan with integration of new

information.

o If patient enrolled in homecare/hospice, does not mean he or she cannot

be enrolled in CCM.

Provider just can’t bill CCM and (G0181, G0182) in same calendar

month.

Practice setting needs to decide which code to use and if available

to use.

The patient is in a service period for certain End-Stage Renal Disease

(ESRD) services (CPT codes 90951-90970).

The patient is still within a 30-day TCM service period (CPT codes 99495-

99496).

Complex CCM and prolonged Evaluation and Management (E/M) services

cannot be reported the same calendar month.

Other considerations:

CPT coding will list specific guidelines for each CCM service code—these are

also listed within this manual (See “9.4 What Codes Can Be Used?”).

Practice settings participating in a CMS sponsored model or demonstration

programs may have restrictions on billing CCM services.

Never bill for CCM services for time that is already counted in another billed

code.

Never bill for CCM services if required 20 minutes of non-face-to-face time was

not reached.


9.3 What Form Should Billing Use?

Billing for CCM services does not require a huge change in the current billing process. A

practice setting would continue to use the same forms and process to bill for patient visits.

This means that whatever rules already apply for billing a patient visit, will also apply to

the monthly billing of CCM services. Here are some of the common settings:

RHC—Provider or Independent Based o Use form UB 04 (CMS 1450) o Type of bill is 0711

FQHC—Provider or Independent Based o Use form UB 04 (CMS 1450) o Type of bill is 0771

Hospital Outpatient Clinic o Typically use form UB 04 (CMS 1450) o Type of bill is can vary

CAH Outpatient Clinic o Typically use form UB 04 (CMS 1450) o Type of bill is 085x

Independent Clinic o Typically use form UB 04 (CMS 1450) o Type of bill is 073x

If a practice setting still has questions or searches for more clarity, it is always suggested

to check for answers before proceeding. Sometimes, unique practice settings may exist

that fall outside the normal scope of service guidelines. Both of these situations would

prompt follow through to gain clear answers from a governing body. This can be done by

contacting CMS, MAC providers, or any Fiscal Intermediary through which the practice

setting coordinates its billing.

9.4 What Codes Can Be Used?

The content in this section is probably the most important information that is available

within this manual. For a CCM program to be successful, it is critical that the care

team/billing department develops a thorough knowledge of the different CCM codes that

are available. It is important to be able to identify each code, to understand what each


code requires for billing, and to determine if a code is available for a practice setting to

use.

Following is a list of codes that are associated with CCM services. Some codes are specific

to CCM, while others may be used during a practice setting’s care coordination process.

Each code has specific guidelines that need to be met to be able to bill for them

successfully. The purpose of this information is to provide education about what each

code means, what elements are required for each code, and what billing parameters

should be followed. It is important to understand that some codes may not be available

for billing to all practice types:

99490: Non-complex CCM service

o Basic CCM service code

o 20 minutes non-face-to-face time with patient

Clinical staff time counted / provider time not required but can

be counted

The manual provides list of activities that can be included (See

“8.1 What Activities Can Be Counted in Those 20 Minutes?”)

o Bill one time per calendar month

Patient pays copay

Yearly deductible applies

o All billing types can bill this code

o See CCM Reference tool below for codes that should not be billed with

this code

99487: Complex CCM service

o 60 minutes of non-face-to-face time with patient


be counted

Provider should be involved though, due to complexity

level

Provider would be interacting with either patient or care

team regarding patient’s condition and interventions for

care

Establish/revise comprehensive care plan

Moderate or high complex medical decision making

o Bill one time per calendar month:


Cannot bill both 99490 and 99487—chose one or the other only

Patient pays copay


o Not available to RHC or FQHC for billing


this code

99489: Complex CCM service – add on

o Additional 30 minutes of non-face-to-face time with patient

Continues the work started under code 99487

Est/revise care plan, moderate/high complex medical decisions


be counted:

Provider should be involved though, due to complexity

level

Provider would be interacting with either patient or care

team regarding patient’s condition and interventions for

care

o Bill one time per calendar month

Add on code to 99487 only—cannot bill alone

99487 (60 min.) + 99489 (30 min.) = 90 min. total

Enter on bill: 99487 + 99489 X 1

If reach an additional 30 min, enter on bill: 99487 + 99489 X 2

Patient pays only 1 copay for original code 99487



this code

99497: Advanced care planning (ACP)

o 30 minutes of face-to-face time with patient, family member, and/or

surrogate

Provider time counted only / cannot count clinical staff time

Counsel/discuss patient on advanced directive options (some

examples: Health Care Proxy, Durable Power of Attorney for

Health Care, Living Will, Medical Orders for Life-Sustaining

Treatment)


May/may not fill out necessary legal forms during this time

No active management of chronic conditions done during this

time

Note: Name is confusing—not working on whole care plan, only

addressing advanced directives part of care plan and related

paperwork

o Bill when service provided, no limit as to how many times or how often

CMS expects to see documented changes in patient’s health status and/

or wishes regarding end-of-life care

o Can be billed as a stand-alone code OR with other codes

Patient pays copay/ yearly deductible applies

Can bill with most E/M visits, CCM, TCM, Global surgical dates of

service

Can bill with E/M visits even if not on same date of service

o Account time for ACP separate from E/M time

o If patient requires extensive time/management,

may consider billing for higher level of E/M instead

of using ACP code

Cannot bill with same date of service as certain critical care

services including neonatal and pediatric critical care

Can bill with AWV if provided as part of that visit

If billed with AWV the patient does not pay a copay

Use modifier-33 to wave patient copay

o All billing types can bill this code

RHC/ FQHC can bill for this code as a stand-alone visit code but

RHC paid at AIR visit rates, not National Payment Amount

FQHC paid PPS visit rates, not National Payment Amount

Allowed as reason for billable scheduled visit by itself

If billed with other visit, code will only get payment for 1

visit not both

o If billed with AWV can still wave copay

o See ** RHC ACP BILLING EXAMPLE below


this code


** RHC ACP BILLING EXAMPLE – BILLED WITH AWV/MWV

Revenue

Code HCPCS

Service

Date

Service

Units

Total

Charges Payment

Coinsurance/

Deductible

Applied

52x

G0438

or

G0439

01/01/2016 1 $XX.XX AIR No

52x 99497 01/01/2016 1 $XX.XX Included

in the AIR No

99498: Advanced care planning - add on

o Additional 30 minutes of face-to-face time with patient, family member,

and/or surrogate

Continues work started under code 99497 (see work elements

listed under code 99497)


o Bill when service provided, no limit as to how many times or how often

Add on code to 99497 only—cannot bill alone

99497 (30 min.) + 99498 (30 min.) = 60 min. total

Enter on bill: 99497 + 99498 X 1

If reach an additional 30 min., enter on bill: 99497 + 99498 X 2

Same billing parameters as 99497 – see information above


this code

G0506: Comprehensive Assessment and Care Planning – add on code

o CMS does not state a required time limit for this code, but

Provider time only / cannot count clinical staff time

Time counted should equal: Time for visit code + time for G0506

Per CMS: “Personally performs extensive assessment and CCM

care planning beyond the usual effort described by the

separately billable CCM initiating visit”

Work with patient to develop and outline care plan elements

Complete comprehensive assessment of patient needs/problems

o Add on code to initiating CCM visit only—cannot bill alone

Initiating visit: AWV, MWV, IPPE, E/M level 2-5, or TCM


Could bill along with 99490, 99487, or 99489 as these count

clinical staff time and G0506 is provider time; would need to be

able to account time separately

Standard patient copay rules apply as required per visit type

o One-time billable service only—bill at onset of CCM services with

initiating visit



this code

99495: Transitional Care Management (TCM)

o Contact patient/caregiver (direct contact, telephone, electronic) within

2 business days from day of discharge from hospital

o Face-to-face visit with provider required within 14 days of discharge

from hospital

Medical decisions at moderate complexity level during visit or

contact

Medication reconciliation required during visit or contact

o Starts day of discharge from hospital through the next 29 days (30-day

period)

o Can bill for services once face-to-face visit is completed, BUT service

period does not end until final 30-day date

o All billing types able to bill this code

RHC and FQHC can bill for this code as a stand-alone visit code

but

RHC will only be paid at AIR visit rates not National

Payment Amount

FQHC be paid at PPS visit rates not National Payment

Amount

Can bring patient in for a scheduled visit for this code

alone

If bill with other visit code will only get payment for 1 visit

not both

Patient pays copay



o No restriction on how many times billed, provided service requirements

met

Cannot bill for overlapping TCM periods OR during CCM service

period unless service start and stop dates align correctly (See KEY

NOTE that follows)

TCM period covers 30 days, next TCM period would need to be

outside that original 30 days before its service days can begin

If patient expires before 30th day, cannot bill for TCM services, BUT

if face-to-face completed, could still bill as patient visit code


this code

KEY NOTE: There can be certain situations when it may actually be okay to bill

for both TCM and CCM within the same month. This situation is not

considered typical, and should not routinely be billed on a monthly basis. To

be able to bill for both TCM and CCM within the same month, the following

would occur, and for this example, February has been randomly chosen:

o Patient’s TCM services begin February 10th

o TCM services run through 30-day service period and end March 11th

o Then patient’s CCM services begin March 12th

o By March 31st, required 20 minutes of non-face-to-face time for

CCM patient has been satisfied

o Days counted for TCM do not overlap with any CCM service dates

o Requirements for billing both TCM and CCM services have been met

o Both TCM and CCM are billed for patient in March

99496: Transitional Care Management (TCM)

o Contact patient/caregiver (direct contact, telephone, electronic) within

2 business days from day of discharge from hospital

o Face-to-face visit with provider required within 7 days of discharge

from hospital

Medical decisions at high complexity level during visit or contact

Medication reconciliation required during visit or contact

o Starts day of discharge from hospital through the next 29 days (30-day

period)

o Can bill for services once face-to-face visit is completed, BUT service

period does not end until final 30-day date


o All billing types able to bill this code

RHC and FQHC can bill for this code as a stand-alone visit code

but

RHC will only be paid at AIR visit rates not National

Payment Amount

FQHC be paid at PPS visit rates not National Payment

Amount

Can bring patient in for a scheduled visit for this code

alone

If bill with other visit code will only get payment for 1 visit

not both

Patient pays copay


o No restriction on how many times billed, provided service requirements

met

Cannot bill for overlapping TCM periods

TCM period covers 30 days, next TCM period would need to be

outside that original 30 days before its service days can begin

If patient expires before 30th day, cannot bill for TCM services, BUT

if face-to-face completed, could still bill as patient visit code


this code

99358: Prolonged Evaluation & Management (E/M) services

o New option to bill separately for this code as of 1/1/2017

o 60 minutes of non-face-to-face time with patient

Must be related to an E/M visit

The 60 minutes of work is done prior to the E/M visit or after

Work done on same day as E/M visit, but can be before

and after visit—does not have to be continuous 60 minutes

Time counted cannot include the E/M visit time


o RHC and FQHC will not receive additional reimbursement

o No limit to how many times billed, provided service guidelines are met

o Standard patient copay for E/M visit only



this code

99359: Prolonged Evaluation & Management (E/M) services – add on

o New option to bill separately for this code as of 1/1/2017

o 30 minutes of additional non-face-to-face time with patient

Must be added on to code 99358—cannot list alone

Will need to complete total of 90 minutes of non-face-to-face

work

99358 = 60 minutes + 99359 = 30 minutes > 90 minutes

total

Must be related to an E/M visit

The 90 minutes of work is done prior to the E/M visit or after:

Work done on same day as the E/M visit, but can be before

and after visit—does not have to be continuous 90 minutes

Time counted cannot include the E/M visit time


o RHC and FQHC will not receive additional reimbursement

o No limit to how many times billed, provided service guidelines are met

o Standard patient copay for E/M visit only


this code


CODE DESCRIPTIONADD ON

TO CODE

MINUTES

REQUIRED

CLINICAL

STAFF

TIME

PROVIDER

TIME

RHC/FQHC

CAN BILL

DO NOT BILL ALONG WITH

THESE CODES

99490

NON

COMPLEX

CCM

20 X X- OPTIONALX

$42.71

90951-90970, 98960-98962,

98966-98969, 99071, 99078,

99090, 99091, 99339, 99340,

99358, 99359, 99362, 99364,

99366-99368, 99374-99380,

99441-99444,99487, 99495,

99496, 99605-99607, G0181,

G0182

99487COMPLEX

CCM60 X

X-

OPTIONAL,

BUT

SHOULD BE

INVOLVED

90951-90970, 98960-98962,

98966-98969, 99071, 99078,

99090, 99091, 99339, 99340,

99358, 99359, 99362, 99364,

99366-99368, 99374-99380,

99441-99444,99490, 99495,

99496, 99605-99607

99489COMPLEX

CCM ADD ON99487

30

ADDITIONAL

MINUTES

X

X-

OPTIONAL,

BUT

SHOULD BE

INVOLVED

90951-90970, 98960-98962,

98966-98969, 99071, 99078,

99090, 99091, 99339, 99340,

99358, 99359, 99362, 99364,

99366-99368, 99374-99380,

99441-99444,99490, 99495,

99496, 99605-99607

99497

ADVANCED

CARE

PLANNING

(ACP)

30 X-ONLY

X

*WILL GET

AIR/PPS

VISIT RATES

99291, 99292, 99468, 99469,

99471, 99472, 99475- 99480

99498 ACP ADD ON 99497

30

ADDITIONAL

MINUTES

X-ONLY

X

*WILL GET

AIR/PPS

VISIT RATES

99291, 99292, 99468, 99469,

99471, 99472, 99475- 99480

CHRONIC CARE MANAGEMENT - CARE COORDINATIONCODE & INFORMATION REFERENCE TOOL


CODE DESCRIPTIONADD ON TO

CODE

MINUTES

REQUIRED

CLINICAL

STAFF

TIME

PROVIDE

R TIME

RHC/FQH

C CAN

BILL

DO NOT BILL ALONG WITH

THESE CODES

G0506COMPREHENSIVE

ASSESSMENT &

CARE PLAN

ANY CCM

INITIATING

VISITN/A X- ONLY G0505, 99358, 99359

99495

TRANSITIONAL

CARE

MANAGEMENT (MODERATE

COMPLEXITY)

N/A2 DAY

CALL POST

HOSP D/C

14 DAY

POST

HOSP D/C

VISIT

X

*WILL GET

AIR/PPS

VISIT RATES

90951-90970, 98960-98962, 98966-

98969, 99071, 99078, 99080,

99090, 99091, 99339, 99340,

99358, 99359, 99363, 99364,

99366-99368, 99374-99380, 99441-

99444, 99487-99489,99490, 99605-

99607, G0181, G0182

99496

TRANSITIONAL

CARE

MANAGEMENT (HIGH

COMPLEXITY)

N/A2 DAY

CALL POST

HOSP D/C

7 DAY

POST

HOSP D/C

VISIT

X

*WILL GET

AIR/PPS

VISIT RATES

90951-90970, 98960-98962, 98966-

98969, 99071, 99078, 99080,

99090, 99091, 99339, 99340,

99358, 99359, 99363, 99364,

99366-99368, 99374-99380, 99441-

99444, 99487-99489, 99490,

99605-99607, G0181, G0182

99358PROLONGED

E/M SERVICES

E/M VISIT

CODE *CAN

BE DONE

BEFORE/AFTE

R VISIT

60 X - ONLY99487, 99489, 99490, 99495,

99496, G0506, INITIATING CCM E/M

VISIT CODE

99359PROLONGED

E/M SERVICES

ADD ON99358

30 ADDITIONAL

MINUTES

X - ONLY99487, 99489, 99490, 99495,

99496, G0506, INITIATING CCM E/M

VISIT CODE

CHRONIC CARE MANAGEMENT - CARE COORDINATIONCODE & INFORMATION REFERENCE TOOL


9.5 Other Miscellaneous Codes

There are other ancillary codes that will accompany the CCM billing codes onto the billing

forms. The following are some key codes to point out:

Revenue code 052x

Typical revenue code used with billing CCM by an RHC/FQHC.

Modifier-25

Use if perform an E/M visit and a CCM service on same day.

Modifier-59

Can be used to distinguish two different “timed” services that happened

on the same date of service—not a typical code to use.

Modifier-33

o Typically use if billing 99497(ACP) and an AWV, MWV, IPPE on same

date of service.

o Allows for patient copay to continue to be waived.

9.6 Submitting the Claim

Billing can be a very time consuming and confusing process when trying to incorporate

all the correct rules and regulations. Many times, a biller will perform all of the required

steps correctly, and still a claim may come back denied. The best way to avoid confusion

is to keep the billing process as simple as possible. These are some suggestions to keep

in mind when billing for CCM:

Billing can submit claim for CCM services once 20 minutes of non-face-to-face

time is accumulated, BUT it is suggested to wait until end of the calendar

month.

o Reason: CCM covers the 1st through 30-31st of each calendar month, and

claims within these dates of service may cause confusion when billing

prior to 30-31st.

o Reason: Waiting until end of month should capture all CCM patients.

Billing should review current claims and services before submitting for CCM

services.

Reason: Identify codes/services that can’t be billed within the same calendar

month.


Billing should consistently submit CCM claims the same time every calendar

month.

o Reason: Allows for routine to be established which promotes efficiency.

o Reason: Reduces errors and missed patients if care team knows target

date.

Billing should apply chronic condition codes to claims—at least two qualifying

conditions. If there are multiple, then apply conditions that are the primary

focus that calendar month.

o Reason: CMS has not mandated what must be placed on claims at this

time.

o Reason: Applying chronic conditions codes is most obvious option and

establishes standard process to avoid confusion.

o Reason: Allows identification of chronic conditions and accumulated

treatments.

Billing should try to submit CCM services claims separately from other services

when possible.

o Reason: Keeps claim submission process simple and avoids confusion.

o Reason: CMS has outlined different options for claim submission, but

can be confusing to remember which codes/modifiers/etc. to use.

o Reason: Claim denials are routinely due to coding errors—submitting

CCM claims separately from other services reduces confusion and

possible errors.

The “place of service” will be the location where face-to-face services are

typically furnished—If the provider practices in a hospital outpatient

department, list “22” on claim form.

o Reason: Place of service will affect payment rate as either facility or non-

facility (facility rate is lower than non-facility rate).

o Reason: If code wrong and higher payment is received, CMS will recoup

overpayment.

Billing considerations if the provider practices in a hospital outpatient

department.

o Reason: Place of service “22” on claim identifies as outpatient and facility

rate.

o Reason: Allows for billing by provider as well as hospital outpatient

department.


Provider paid at facility rate for providing hospital staff direction.

Hospital outpatient department may also bill under OPPS

(compensates hospital for costs associated with clinical staff

furnishing non-face-to-face services and related expenses).

“Incident-to” services are always billed under that patient’s provider/

practitioner’s NPI number —rule applies to CCM services billing as well.

Reason: A nurse practitioner allowed under CMS regulations to provide

CCM services would not use a primary provider NPI or group TIN, but would

use a nurse practitioner NPI to identify his or her role in CCM services and

meet to CMS regulations.

One of the main catalysts for a claim to be denied is confusion. Confusion leads to errors,

and errors lead to claim denials. It is important that the individual who is billing for the

practice understands how to appropriately complete a CCM claim. Using the simplest

options when submitting claims, such as billing CCM services separately from other

services, will decrease confusion for both the biller and the entity that processes the claim.

Any questions or confusion that exists should always be answered prior to initiating the

CCM claims process. After reviewing the content within this manual, the billing

department should have a good understanding of the codes associated with CCM, and

the forms used for submitting claims.

A practice setting that correctly implements all CCM services and then submits a correct

CCM claim, should receive reimbursement for that claim. If a practice setting does receive

a denial, it is suggested to check with the MAC/FI to help identify what problem has

occurred. The MAC/FI will also be able to give further direction that will help fix the

problem, and avoid future denials.


CHAPTER 10 INFORMATION AND

RESOURCES

CMS Care Management page:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/PhysicianFeeSched/Care-Management.html

Motivational Interviewing resources:

Motivational Interviewing: Preparing People for Change (Miller and Rollnick, 1991;

2001 & 2012)

Health Behavior Change: A Guide for Practitioners (Rollnick, Mason & Butler, 1999)

Motivational Interviewing in Health Care (Rollnick, Miller & Butler, 2008)

ICAHN – IRCCO website:

http://www.icahn.org/

Centers for Medicare & Medicaid Services:

Physicians Fee Schedule Look Up: https://www.cms.gov/Medicare/Medicare-Fee-

for-Service-Payment/PFSLookup/index.html?redirect=/pfslookup

General Website: https://www.cms.gov/

TCM fact sheet MLN page: https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/

Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf

Improving Chronic Illness Care resources and tools:


Bizmed Toolbox sign up for free account/ contains CCM tool:


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Care-Management.html


http://www.amazon.co.uk/Health-Behavior-Change-Pip-Mason/dp/0702031534





https://www.cms.gov/







Bibliography

Miller, W.R. & Rollnick, S.. (2002). Motivational interviewing: preparing people for

change. New York, NY: Guilford Press.

Rollnick, S., Mason, P. & Butler, C.C.. Health behavior change: a guide for practitioners.

(2008). London, England, UK: Churchill-Livingstone.

Rollnick, S., Miller, W.R. & Butler, C.C.. Motivational interviewing in health care. (2008).

New York, NY: Guilford Press.

Chronic care management services. (2016, December). Retrieved from

https://cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/ChronicCareManagement.pdf, p.2.

Chronic care management services. (2016, December). Retrieved from

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNProducts/Downloads/ChronicCareManagement.pdf, p.5.

Chronic conditions data warehouse. (2017). Retrieved from www.ccwdata.org.

Electronic health records (EHR) incentive programs. (2017, February 08). Retrieved from

https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/.

Federal register. (current). Retrieved from www.federalregister.gov.

Regulations & guidance centers for medicare & medicaid services. (current). Retrieved

from www.cms.gov.

https://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

https://cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf



http://www.federalregister.gov/

http://www.cms.gov/


ABOUT THE AUTHOR

Lesa Schlatman began her nursing career 23 years ago as an RN, and is currently the

Care Coordinator Specialist for both ICAHN and IRCCO. Her ethical knowledge base is

rooted in her love for the Aging Adult population, and has grown through her experiences

in bedside nursing; skilled care settings; managerial positions; and regulatory/compliance

oversight.

Lesa grew up in a small rural town, where she experienced the hardship of chronic illness

first hand through the care of her beloved grandfather. Her passion to make a difference

flourished from that point forward. During her years across numerous healthcare settings,

Lesa contributed to varied initiatives that helped transform and improve the quality of

care being delivered to patients. She hopes that her latest work will help readers achieve

care models that make a difference to the populations they serve.

Copyright © 2017 by Lesa Schlatman RN, BSN. All rights reserved. This book or any

portion thereof may not be reproduced or used in any manner whatsoever without the

express written permission of the publisher.

Printed in the United States of America

First Printing: 2017

ICAHN (Illinois Critical Access Hospital Network)

245 Backbone Road East

Princeton, Illinois 61356

www.icahn.org


NOTES____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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245 Backbone Road East | Princeton, Illinois 61356 | 815.875.2999 | www.icahn.org

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CHRONIC CARE MANAGEMENT - hthu.net · Chronic Care Management THE GATEWAY TO QUALITY CARE OVERVIEW Chronic Care Management (CCM) ... Any patient not attributed to the CPCI model can