HCCIntelligence™ Live Webinar: 2022 Coding & Policy Impacts: What Home-Based Providers and Practices Need to Know! - December 2021-Chronic Care Management Care Plan Requirements Resource

Chronic Care Management Care Plan Requirements Resource

Pdf Summary

The document serves as a resource for home-based primary care (HBPC) providers and practice staff, offering an overview of the essential components required for a Chronic Care Management (CCM) Care Plan. It is designed to act as a guideline for creating a standard CCM Care Plan but emphasizes referring to CMS guidelines for comprehensive details.<br /><br />**Key CCM Service Elements:**<br />- Practices must use certified Electronic Health Record (EHR) technology for structured patient health information recording.<br />- Maintain a comprehensive electronic care plan.<br />- Manage transitions and coordinate patient health information both inside and outside the practice.<br />- Provide other care management services.<br /><br />**Care Plan Requirements (as amended in the 2020 Medicare Physician Fee Schedule final rule):**<br />- Problem list<br />- Expected outcome and prognosis<br />- Measurable treatment goals<br />- Cognitive and functional assessment<br />- Symptom management<br />- Planned interventions<br />- Medical management<br />- Environmental evaluation<br />- Caregiver assessment<br />- Interaction and coordination with external resources and practitioners<br />- Requirements for periodic review and care plan revisions<br /><br />**Additional Required Service Elements:**<br />- Document verbal consent, informing the patient/caregiver about service availability, billing details, the right to terminate services, and cost-sharing.<br />- Conduct an initiating visit for new patients or members not seen in the past twelve months.<br />- Provide 24/7 access to care, ensuring after-hours coverage.<br />- Establish a relationship with a designated care team member to ensure continuity of care.<br />- Implement comprehensive care management and electronic care plan, ensuring availability within and outside the practice.<br />- Manage care transitions and referrals, maintaining timely exchange of care documents and follow-up.<br />- Coordinate home and community-based care, including communication with service providers about psychosocial and functional deficits.<br />- Enhance communication opportunities, offering non-face-to-face methods such as secure emails or patient portals.<br /><br />The document also promotes resources provided by the HCCIntelligence Resource Center, including webinars, virtual office hours, and downloadable tools to support HBPC providers.<br /><br />For further assistance, contact the HCCIntelligence hotline or explore the HCCInstitute website.

Keywords

Home-based primary care

Chronic Care Management

Care Plan

Electronic Health Record

CMS guidelines

Medicare Physician Fee Schedule

Care transitions

Patient health information

Caregiver assessment

HCCIntelligence Resource Center