Care management and care planning services use a multidisciplinary team approach to assist individuals in managing their medical, mental, or behavioral health conditions more effectively.
ADVANCE CARE PLANNING
Advance care planning (ACP) is the the face-to-face service between a professional provider or other qualified healthcare professional and the patient/individual discussing advance directives, with or without completing relevant legal forms. ACP services are time-based services. No other active management of the individual’s health conditions should be undertaken for the time recorded when ACP service codes are reported. Brief conversations of a few minutes (performed during an Evaluation and Management [E/M] service) related to wishes concerning potential emergent resuscitation do not represent ACP services. The face-to-face time is defined as only that time spent face-to-face with the individual with or without the presences of surrogate(s) such as a healthcare agent, designated decision maker, family member, or caregiver.
An advance directive is described as a written document that an individual uses to appoint a representative and/or to record the individual's wishes as it relates to future medical treatment in the event the individual is incapacitated and unable to make decisions on their own. Types of written advance directives include, but are not limited to:
CHRONIC CARE MANAGEMENT AND COMPLEX CHRONIC CARE MANAGEMENT Chronic Care Management (CCM) and Complex Chronic Care Management (CCCM) refer to care coordination services provided to individuals with two or more chronic conditions expected to last at least 12 months or for the remainder of an individual's life. These chronic conditions place the individual at significant risk of death, acute exacerbation/decompensation, or functional decline.CCM services have the same criteria and components as (CCCM) services. According to the Centers for Medicare & Medicaid Services (CMS), CCM and CCCM differ in the amount of clinical staff service time directed by a professional provider or other qualified healthcare professional; the involvement and work of the billing professional provider or other qualified healthcare professional; and the extent of care planning performed. The estimated work time for CCCM services is 60 minutes per month, while the work time for CCM services is at least 20 minutes.In furnishing CCCM services, the professional provider or other qualified healthcare professional and clinical staff develop a holistic care plan that addresses all aspects of the individual's healthcare needs, including all medical conditions, psychosocial needs, and activities of daily living. Whereas the professional provider or other qualified healthcare professional might not singly furnish all the included components of a CCCM care plan, the provider is nonetheless expected to coordinate all of the included components and update the plan as needed to address any changes in an individual's health needs.A CCCM plan is typically implemented by clinical staff under the direct supervision of the professional provider or other qualified healthcare professional. In implementing the plan, the staff members typically perform many, if not all, of the following tasks:
- Healthcare proxy
- Durable power of attorney for healthcare
- Living will
- Medical orders for life-sustaining treatment (MOLST)
- Communicate and engage with the individual, family members, guardian or caretaker, surrogate decision makers, and/or other professionals regarding aspects of the individual's care.
- Communicate with home health agencies and other community services utilized by the individual.
- Collect and document health outcomes data.
- Provide individual and/or family/caretaker education to support self-management, independent living, and activities of daily living.
- Assess and support the individual's treatment regimen adherence and medication management.
- Identify available community and health resources for the individual and facilitate access to care and services needed by the individual and/or family.
- Develop, communicate, and maintain the individual's comprehensive care plan.
COMPREHENSIVE MANAGEMENT AND CARE COORDINATION FOR ADVANCED ILLNESS Comprehensive management and care coordination for advanced illness (CMCCAI) refers to the management of members with one chronic condition, rather than multiple (two or more) chronic conditions.CMCCAI includes the following services for members with ONE chronic condition:
- Assess for the presence of symptoms on at least a monthly basis
- Develop a treatment plan to manage symptoms
- Educate about cause and management of symptoms
- Assess for psychosocial and spiritual distress and refer for support
- Provide information regarding prognosis consistent with the individual's preferences
- Establish goals of care that are consistent with the individual's values and preferences
- Maintain an 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
TRANSITIONAL CARE MANAGEMENT
Transitional Care Management (TCM) refers to care coordination services provided to an individual whose medical and/or psychosocial condition(s) require moderate- or high-complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the individual's community setting (home, domicile, rest home, or assisted living).