Commercial

Care Management and Care Planning Services
00.01.59h

Policy

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

The Company covers the following care management and care planning services; however, these services are not eligible for separate reimbursement whether billed alone or in conjunction with other services. Participating professional providers may not bill members for these services. 
  • Advanced Care Planning (ACP)
  • Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM)
  • Comprehensive Management and Care Coordination for Advanced Illness (CMCCAI)
  • General Behavioral Health Integration (BHI)
  • Psychiatric Collaborative Care Management (CoCM)
ELIGIBLE

TRANSITIONAL CARE MANAGEMENT (TCM)
Transitional Care Management (TCM) services are covered and eligible for reimbursement consideration by the Company when ALL the following requirements are met:
  • The individual has medical and/or psychosocial problems that require moderate or high complexity medical decision making.
  • Communication with the individual or the individual's caretaker occurs within two business days of discharge by either direct (face-to-face), or indirect (telephonic or electronic) means.
    • If the individual is not reached within two business days, the provider may still be able to furnish TCM services provided the individual is reached in enough time for a face-to-face visit to occur within the established time frame (see face-to-face requirements below).
    • The provider must document all unsuccessful attempts in reaching the individual, beginning at a minimum of two business days post-discharge, until contact is eventually established.
  • The face-to-face visit must occur within either seven calendar days post discharge (for an individual whose condition requires high-complexity decision making) or 14 days post-discharge (for an individual whose condition requires moderate complexity decision making).
    • If the face-to-face visit occurs outside this period (e.g., because the member could not be reached in enough time for a face-to-face visit to occur within either seven or 14 days), then the provider has NOT provided TCM services. In such cases, the provider should report the appropriate E/M service furnished based on medical necessity if and when the member is eventually reached.
  • Medication reconciliation and management occurs no later than the date of the face-to-face visit.
BILLING REQUIREMENTS

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

WHEN NOT TO REPORT TCM SERVICES
  • When the professional provider reports a procedure with an assigned global​ period (eg, 10 days, 90 days); in this instance, TCM services are included in the post-operative payment for the procedure.
  • When the individual is discharged from the hospital to a skilled nursing facility.
  • Evaluation & Management (E&M) services performed on the day of discharge as part of the discharge management services cannot be considered the TCM face-to-face visit.
REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

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

Guidelines

BENEFIT APPLICATION

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

Description

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

ADVANCE CARE PLANNING (ACP)

Advance care planning (ACP) is the the face-to-face service between a professional provider or other qualified healthcare professional and the patient/individual discussing advance directives, with or without completing relevant legal forms. An advance directive is a document appointing an agent and/or records the wishes of a patient/individual pertaining to his/her medical treatment at a future time should he/she lack decisional capacity.

CHRONIC CARE MANAGEMENT (CCM) AND COMPLEX CHRONIC CARE MANAGEMENT (CCCM)

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

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

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

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

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

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

General Behavioral Health Integration (BHI) are monthly services provided using BHI models of care other than Psychiatric Collaborative Care Management (CoCM) that similarly include “core” service elements such as systematic assessment and monitoring, care plan revision for individuals whose condition is not improving adequately, and a continuous relationship with a designated care team member. General BHI may be used to report models of care that do not involve a psychiatric consultant, nor a designated behavioral health care manager, although these providers may perform General BHI services.

General Behavioral Health Integration (BHI) refers to the integration of behavioral health with primary care as a strategy for improving outcomes for individuals with mental or behavioral health conditions.

PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT (CoCM)

Psychiatric CoCM refers to services provided to an individual seen in a primary care setting who is diagnosed with a mental health or substance abuse disorder. CoCM is a model under BHI services that utilizes regular psychiatric inter-specialty care for individuals receiving BHI treatment. Psychiatric care services are provided through the primary care professional provider or other qualified healthcare professional in collaboration with a psychiatric professional provider or other qualified healthcare professional​, who reviews the clinical status of the individual and makes recommendations. The primary care team weekly reviews the individual's treatment plan and status with the psychiatric consultant and maintains or adjusts the treatment plan with referrals to specialities in behavioral health as needed.

TRANSITIONAL CARE MANAGEMENT (TCM)

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

References

Centers for Medicare and Medicaid (CMS). MLN Fact Sheet. Chronic Care Management Services. December 2016. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf. Accessed November 15, 2020.

Centers for Medicare and Medicaid (CMS). Frequently Asked Questions about Billing Medicare for Behavioral Health Integration (BHI) Services. January 2018.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf. Accessed November 15, 2020.

Centers for Medicare and Medicaid (CMS). MLN Fact Sheet. Advance Care Planning. August 2016. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf. Accessed November 15, 2020.

Centers for Medicare and Medicaid (CMS). MLN Fact Sheet. Transitional Care Management Services. August 2016. Available at:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. Accessed November 15, 2020.

Frequently Asked Questions about Billing Medicare for Behavioral Health Integration (BHI) Services January 3, 2018. Available at:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Behavioral-Health-Integration-FAQs.pdf. Accessed November 15, 2020.

OptumCoding. The Challenge of Coding Complex Chronic Care Coordination. Available at:https://www.optumcoding.com/CodingCentralArticles/?id=1544. Accessed November 15, 2020.

Coding

CPT Procedure Code Number(s)
99439, 99484, 99487, 99489, 99490, 99491, 99492, 99493, 99494, 99495, 99496, 99497, 99498

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

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

HCPCS Level II Code Number(s)

G0506Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)
​G0511Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month
G0512Rural health clinic or federally qualified health center (RHC/FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month
G2064Comprehensive care management services for a single high risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities
G2065Comprehensive care management for a single high risk disease services, e.g., principal care management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities
G2214Initial or subsequent psychiatric collaborative care management, first 30 minutes in a month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified health care professional​​

S0257Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate (list separately in addition to code for appropriate evaluation and management service)
S0311Comprehensive management and care coordination for advanced illness, per calendar month​



Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

1/4/2021
1/4/2021
00.01.59
Claim Payment Policy Bulletin
Commercial
No