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Medical Coding News Archives

The Challenge of Coding Complex Chronic Care Coordination

 
February 26, 2014:

Nichole VanHorn, Clinical/Technical Editor

The complexity of the codes for chronic care coordination services challenge any coder. Added to that are the specific guidelines for reporting these services in the American Medical Association’s CPT® book. For these reasons, it is crucial to have a solid understanding of how to report these services before submitting claims.

Chronic care coordination is generally provided for chronically ill patients who have continuous or episodic health conditions. These patients live in assisted living facilities, at home, in a domiciliary, or a rest home. The services are not reported by location as are other coordination services and are in part performed by clinical staff. The clinical staff develops, implements, and many times substantially revises the care plan under the direction of the physician or other qualified health care professional.

According to the CPT manual, “substantial revision to a care plan typically occurs when the patient’s clinical condition changes sufficiently (e.g., identification of a new problem requiring additional interventions, introduction of new interventions because existing interventions are deemed ineffective, exacerbation of an existing problem requiring new interventions) to require more intensive staff monitoring, changes in the treatment regimen, and additional time to educate the patient and/or caregiver about the patient’s condition and/or change in treatment plan and prognosis.”

Such patients typically require coordination of multiple medical specialties and services. In addition, they have multiple illnesses and medications, are unable to perform daily activities, require a caregiver, and have repeat visits to the emergency room and hospital admissions. In general, the following describe the criteria that must be met to assign codes for complex chronic care coordination services for an adult and pediatric patient, respectively.

An adult patient:

  • Takes or receives three or more prescription medications
  • May receive therapeutic interventions such as physical or occupational therapy
  • Has two or more chronic continuous or episodic health conditions. The duration of the conditions is expected to be at least 12 months or until the death of the patient, or the conditions place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline.

A pediatric patient:

  • Takes or receives three or more prescription medications or therapeutic interventions (e.g., medications, nutritional support, respiratory therapy)
  • Has two or more chronic continuous or episodic health conditions. The duration of the conditions is expected to be at least 12 months or until the death of the patient, or the conditions place the patient at a significant risk of death, acute exacerbation/decompensation, or functional decline.

The codes are defined according to whether a face to face service was provided by the physician or other qualified health care professional or not.

Code 99487 is reported when no face-to-face service was performed by the physician or other qualified health care professional. The clinical staff usually spend at least 31 minutes in a calendar month in care coordination activities. Only the time of one clinical staff may be counted if multiple staff members are meeting regarding the patient. Code 99488 includes one face-to-face visit by the physician or other qualified health care professional and reports the first hour of clinical staff time directed by the provider in a calendar month. Add-on code 99489 is used to report each additional 30 minutes of clinical staff time directed by the provider regardless of whether a face-to-face visit has been performed or not. Less than 30 minutes should not be reported with these codes.

The services that may be provided by the clinical staff include:

  • Assessment and support for treatment regimen adherence and medication management
  • Collection of health outcomes data and registry documentation
  • Communication with home health agencies and other community services the patient may use
  • Communication and engagement with the patient, family members, caretaker or guardian, surrogate decision makers, and/or other professionals regarding aspects of care
  • Development, communication, and maintenance of a comprehensive care plan
  • Education of patient and/or family/caretaker to support the self-management, independent living, and activities of daily living
  • Facilitation of access to care and services needed by the patient and/or family
  • Identification of available community and health resources

When a physician or qualified health care professional performs any of the clinical staff activities described in these codes, his/her time may be counted towards the clinical staff time to meet the requirements of the elements of the code.

After a face-to-face visit has been performed and code 99488 has been reported, the following services may not be reported in the same 30-day period by a physician or other qualified health care professional:

  • Analysis of data (99090–99091)
  • Anticoagulant management (99363–99364)
  • Care plan oversight (99339–99340, 99374–99380)
  • Education and training (98960–98962, 99071, 99078)
  • Medical team conferences (99366–99368)
  • Medication therapy management (99605–99607)
  • Online medical evaluation (98969, 99444)
  • Preparation of special reports (99080)
  • Prolonged services without direct patient contact (99358–99359)
  • Telephone services (98966–98968, 99441–99443)
  • Transitional care management services (99495-99496)

These codes should not be reported by a surgeon if the services he or she rendered are within a global surgery period of the surgical procedure performed. These codes should not be reported in the same 30-day period as codes for end-stage renal disease services (90951–90970).

If any additional evaluation and management (E/M) services are performed after the first visit, they may be reported separately.

Codes for chronic care services are reported only one time per month.

It is important to note that a physician or other qualified health care professional may not report these codes if the patient’s care plan is unchanged or has only minimal changes, such as a medication change or adjustment or new treatment is ordered.

Chronic care codes have very strict guidelines that must be followed. It is important to thoroughly read the guidelines to ensure that the services the provider performs support the medical necessity of these codes. Practices using these codes should perform regular audits on them to ensure that the codes are being properly documented and reported.

 

 
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