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24.3.19.2 Reimbursement
General Requirements for Face-to-Face Clinician-Directed Care Coordination Services
Limitations
Providers should use the most appropriate face-to-face E/M procedure codes to bill for care coordination services.
• When counseling or care coordination requires more than 50 percent of the client, and/or family encounter (face-to-face time in the office or other outpatient setting, or floor or unit time in the hospital), then time may be considered the key or controlling factor to qualify for a particular level of E/M service.
•Counseling is discussion with the client and/or family, concerning diagnostic studies or results, prognosis, risks and benefits, management options, importance of adhering to the treatment regimen, and client and family education.
An E/M procedure code for a face-to-face problem-focused care coordination visit may be billed on the same day as a preventive medicine visit. Modifiers must be used as appropriate for billing.
Any face-to-face inpatient or outpatient E/M procedure code that is a benefit of the CSHCN Services Program, except hospital discharge-day management (procedure codes 1-99238 and 1-99239) and discharge from observation (procedure code 1-99217) may be billed on the same day as any non-face-to-face clinician-directed care coordination, (procedure codes 1-99339, 1-99340, 1-99358, 1-99359, 1-99361, 1-99362, 1-99374, 1-99375, 1-99377, and 1-99378), when the client requires significant, separately identifiable E/M service by the same physician on the same day.
General Requirements for Non-Face-to-Face Clinician-Directed Care Coordination Services
Limitations
These services may be reimbursed for the clinician time involved in this coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to or performed by others do not count towards care coordination reimbursement.
Documentation
Clinician-directed care coordination services must be documented in the client's medical record. Documentation must support the services being billed and must include a record of the clinician's time spent performing specific care coordination activities, including start and stop times. The documentation should also include a formal care plan and emergency services plan.
The supporting documentation maintained in the client's medical records must be dated and include the following components and requirements:
•A current medical summary, containing key information about the client's health (e.g., conditions, complexity, medications, allergies, past surgical procedures, etc.).
•A current list of the main concerns as well as key strengths and assets, and the related current clinical information.
•Planned action steps or interventions to address the concerns and to sustain or build strengths, with the expected outcomes.
•Persons responsible.
•Timeframes and due dates.
The supporting documentation must be reviewed and maintained every six months, or more frequently, as needed.
Client medical records are subject to retrospective review.
Other Requirements
Payment is made for care coordination to a clinician providing post-surgical care during the postoperative period only if the care coordination is documented to be unrelated to the surgery.
Coding and Specific Requirements for Non-Face-to-Face Clinician-Directed Care Coordination Services
Care Plan Oversight
Clinician-directed care plan oversight services may be billed with one of the procedure codes listed in the following table.
Clinician supervision of a client in the home or domiciliary or under the care of a home health agency or hospice (care plan oversight) may be billed with the following procedure codes:
Limitations for Care Plan Oversight Services. The clinician who bills for the care plan oversight must be the same clinician who signed the plan of care for the home or domiciliary (procedure codes 1-99339 and 1-99340), home health agency (procedure codes 1-99374 and 1-99375) or hospice (procedure codes 1-99377 and 1-99378).
Care plan oversight may be reimbursed for the clinician time involved in the coordination. The clinician billing the services must personally perform the services. Care coordination services delegated to or performed by others do not count towards care coordination reimbursement.
Only two clinician-directed care plan oversight services (procedure codes 1-99339, 1-99340, 1-99374, 1-99375, 1-99377, or 1-99378) may be reimbursed every six months.
Procedure code 1-99339 is denied if billed on the same date of service by the same provider as procedure code 1-99340.
Procedure code 1-99374 is denied if billed on the same date of service by the same provider as procedure code 1-99375.
Procedure code 1-99377 is denied if billed on the same date of service by the same provider as procedure code 1-99378.
End-stage renal disease services (procedure codes 1-90918, 1-90919, 1-90920, 1-90921, 1-90922, 1-90923, 1-90924, and 1-90925) apply to a full or partial month of services and are inclusive of all the clinician's supervision services described in care plan oversight (procedure codes 1-99339, 1-99340, 1-99374, 1- 99375, 1-99377, and 1-99378). Care plan oversight may not be reimbursed to the same clinician during the same month as end-stage renal disease services.
Other Requirements. The clinician may not have a significant financial or contractual relationship with the home health agency as defined in 42 Code of Federal Regulations (CFR) 424.
The clinician may not be the medical director or employee of the hospice and may not furnish services under arrangements with the hospice (including volunteering).
Medical Team Conference
Medical conferences may be billed with procedure codes 1-99361 and 1-99362.
Limitations for Medical Team Conferences. One medical team conference (procedure code 1-99361 or 1-99362) may be reimbursed every six months when the coordinating clinician attests that they are providing the medical home for the client. The coordinating clinician may be the client's primary care physician or a specialist.
Additional medical team conferences may be considered with documentation of a change in the client's medical home.
Documentation. The medical team conference time must be documented in the client's record.
Non-Face-to-Face Prolonged Services
Non-face-to-face prolonged services may be billed with procedure codes 1-99358 and 1-99359.
Limitations for Non-Face-to-Face Prolonged Services. The client must be an established client and must have had a face-to-face encounter at least once during the six months immediately preceding provision of the first non-face-to-face prolonged service.
Non-face-to-face prolonged services (procedure codes 1-99358 and 1-99359) are limited to a maximum of 90 minutes once per client per provider. Additional prolonged non-face-to-face services may be authorized if there is one of the following significant changes in the client's clinical condition:
•The client will soon be, or has recently been, discharged from a prolonged and complicated hospitalization requiring coordination of complex care with multiple providers in order for the client to be adequately cared for in the home.
•Documentation of recent trauma resulting in new medical complications that require complex interdisciplinary care.
•The client has a new diagnosis of a medically complex condition requiring additional interdisciplinary care with additional specialists.
Procedure code 1-99359 must be billed for the same date of service as 1-99358.
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