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24.3.19 Clinician-Directed Care Coordination Services
Clinician (physician and/or APN)-directed care coordination services are a benefit of the CSHCN Services Program. These services are payable only to the clinician (primary care or sub-specialist) who is providing the medical home for the client.
In providing a medical home for the client, the primary care clinician directs care coordination together with the client and family.
Care coordination is a family-centered process that links clients with special health-care needs and their families to services and resources in a coordinated effort to maximize the potential of the clients and provide them with optimal health-care.
Clinician-directed care coordination services (face-to-face and non-face-to-face) must include the following activities, with permission of the client or family:
• Supervision of the development and revision of a client's written care plan (a formal document or contained in the client's progress notes) in partnership with the client, family, and other agreed-upon contributors, and sharing of this care plan with other providers, agencies, and organizations involved in the care of the client.
•Coordination of care among multiple providers.
•Maintenance of a central record or database that contains all pertinent client medical information, including hospitalizations and specialty care.
•Assisting the client and family in communicating clinical issues when a client is referred for a consultation or additional care.
•Evaluation, interpretation, and management of consultant recommendations for the client and family in partnership and collaboration with consultants, other providers, the client, and the family.
Clinician-directed care coordination services should also include supervision of development and revision of the client's emergency medical plan in partnership with the client, the family, and other providers to be used 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 E/M services and prolonged services.
Non-face-to-face care coordination services include:
•Prolonged services (procedure codes 1-99358 and 1-99359).
•Medical team conferences (procedure codes 1-99361 and 1-99362).
•Care plan oversight/supervision (procedure codes 1-99339, 1-99340, 1-99374, 1-99375, 1-99377, and 1-99378).
Specifically, non-face-to-face clinician supervision of the development and/or revision of a client's care plan (care plan oversight services) may include the following activities. These services do not have to be contiguous:
•Review of charts, reports, treatment plans, or 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 clinicians (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).
•Documentation of the services provided, including writing a note in the client chart describing services provided, decision making performed, and amount of time spent performing the countable services, including time spent by the physician working on the care plan after the nurse has conveyed pertinent information from agencies or facilities to the physician, including the start and stop times.
The following activities are not covered as non-face-to-face clinician oversight/supervision of the development and/or revision of the client's care plan (care plan oversight services):
•Time that staff spends getting or filing charts, calling the home health agencies, clients, etc.
•Clinician telephone calls to a client or family, except when necessary to discuss changes in client's care plan.
•Clinician time spent telephoning prescriptions in to the pharmacist (not a physician service; does not require a physician to perform).
•Clinician time getting and/or filing the chart, dialing the telephone, or time on hold (these activities do not require clinician work or 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 E/M services.
•Consults with health professionals not involved in the client's case.
•Work included in hospital discharge day management (procedure codes 1-99238 and 1-99239) and discharge from observation (procedure code 1-99217).
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