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2.3 Clinician-Directed Care Coordination Services (CCP)
2.3.1 Services/Benefits and Limitations
Clinician-directed (physician, APRN, and PA) care coordination services are a benefit of CCP for eligible clients who are birth through 20 years of age and have special health needs. These services are payable only to the clinician (primary care, specialist, or sub-specialist) who provides the medical home for the client.
To provide a medical home for the client, the primary care clinician directs care coordination together with the client and family. Care coordination consists of managing services and resources for clients with special health needs and their families to maximize the clients' potential and provide them with optimal health care.
Clinician-directed care coordination services (face-to-face and non-face-to-face) must include the following components:
• A written care plan (either a formal document or documentation contained in the client's progress notes) developed and revised by the medical home clinician, in partnership with the client, family, and other agreed-upon contributors. This plan is shared with other providers, agencies, and organizations involved with the care of the client, including educational and other community organizations with permission of the client or family. The care plan must be maintained by the medical home clinician and reviewed every six months or more frequently as necessary for the client's needs.
•Care among multiple providers that are coordinated through the clinician.
•A central record or database maintained by the medical home clinician containing all pertinent medical information, including hospitalizations and specialty care.
•Assistance for the client or family in communicating clinical issues when a client is referred for a consultation or additional care, such as evaluation, interpretation, implementation, and management of the consultant recommendations for the client or family in partnership and collaboration with other providers, the client, or family.
Clinician-directed care coordination services must also include the supervision of the development and revision of the client's emergency medical plan in partnership with the client, the family, and other providers for use by emergency medical services (EMS) personnel, utility service companies, schools, other community agencies, and caregivers.
Face-to-face care coordination services are encompassed within the various levels of evaluation/management E/M encounters and prolonged services.
Non-face-to-face clinician-directed care coordination services include:
•Prolonged services (procedure codes 99358 and 99359).
•Medical team conference (procedure code 99367).
•Care plan oversight/supervision, including telephone consultations with a specialist or subspecialist (procedure codes 99339, 99340, 99374, 99375, 99377, 99378, 99379, and 99380).
•Specialist or subspecialist telephone consultations (procedure code 99499 with modifier U9)
Non-face-to-face clinician-directed care coordination services are not considered case management by Texas Medicaid.
Specifically, non-face-to-face medical home clinician oversight/supervision of the development or revision of a client's care plan may include the following activities, which do not have to be contiguous:
•Review of charts, reports, treatment plans, and lab or study results, except for the initial interpretation or review of lab or study results ordered during or associated with a face-to-face encounter.
•Telephone calls with other Medicaid-enrolled health-care professionals (not employed in the same practice) involved in the care of the client.
•Telephone or face-to-face discussions with a pharmacist about pharmacological therapies (not just ordering a prescription).
•Medical decision-making.
•Activities to coordinate services, if the coordination activities require the skill of a clinician.
•Documenting the services provided, which includes writing a note in the client's chart describing the services provided, decision-making performed, and the amount of time spent performing the countable services, including the start and stop times and time spent by the physician working on the care plan after the nurse has conveyed pertinent information from agencies/facilities to the physician.
The following activities are not covered as non-face-to-face clinician supervision of the development or revision of the client's care plan (care plan oversight services):
•Time that the staff spends getting or filing charts, calling home health agencies or clients, and similar administrative actions.
•Clinician telephone calls to client or family, except when necessary to discuss changes in client's care plan.
•Clinician time spent telephoning prescriptions to a pharmacist (does not require clinician work and does not require a clinician to perform).
•Clinician time getting or filing the chart, dialing the telephone, or time on hold (does not require clinician work and does not meaningfully contribute to the treatment of the illness or injury).
•Travel time.
•Time spent preparing claims and for claims processing.
•Initial interpretation or review of lab or study results that were ordered during or associated with a face-to-face encounter.
•Services included as part of other evaluation and management (E/M) services.
•Consultations with health professionals not involved in the client's case.
•Work included in hospital discharge day management (procedure codes 99238 and 99239) and discharge from observation (procedure code 99217).
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