Services
CMS recognizes that care management services contribute to better patient health care and outcomes. Medicare reimburses for these services as non-face-to-face care under general supervision. These services can help reduce geographic and racial or ethnic health care disparities. 24OurCare offers the highest quality of Care Management Services with the latest education and technologies in a convenient and comfortable environment. With a team of expert Care Coaches, nurses, and healthcare professionals, our commitment to value-based care is second to none.
Chronic Care Management
Our Flagship Program
99490, 99439, 99487 and 99489 CPT codes
Care management services for patients with 2 or more chronic conditions, under general supervision, with the following required elements:
●Structured recording of patient health information
●Keeping comprehensive electronic care plans
●Continuous patient relationship with chosen care team member ●Supporting patients in achieving health goals
●24/7 patient access to care and health information
●Patient receiving preventive care
●Patient and caregiver engagement
●Prompt sharing and using patient health information
99490 - first 20 minutes of clinical staff time per calendar month
99439 - additional 20 minutes up to 60 mins per calendar month
99487 - complex CCM first 60 minutes per calendar month
99489 - complex CCM additional 30 minutes per calendar month
Principal Care
Management
99426 and 99427 CPT Codes
Care management services for patients with 1 chronic condition expected to last at least 3 months, under general supervision, with the following required elements:
●Structured recording of patient health information
●Keeping comprehensive electronic care plans
●Continuous patient relationship with chosen care team member ●Supporting patients in achieving health goals
●24/7 patient access to care and health information
●Patient receiving preventive care
●Patient and caregiver engagement
●Prompt sharing and using patient health information
99426 - first 30 minutes of clinical staff time per calendar month
99427 - additional 30 minutes per calendar month
Behavioral Health Integration
99484 CPT Code
Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, under general supervision of a physician, per calendar month, with the following required elements:
●Initial assessment or follow-up monitoring
●Behavioral health care planning about behavioral or psychiatric health problems
●Facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling, or psychiatric consultation ●Continuity of care with an appointed member of the care team
Remote Patient (Physiologic) Monitoring
99454 and 99457
Care management service for monitoring certain aspects of a patient's health, under general supervision of a physician, and 20 minutes of clinical staff time, with the following required elements:
●Physiologic data must be electronically collected and automatically uploaded to the secure location where the data can available for analysis and interpretation
●The device used to collect and transmit the data must meet the definition of a medical device as defined by the FDA
●Remote physiologic monitoring data must be collected for at least 16 days out of 30 days
●Remote physiologic monitoring services must monitor an acute care or chronic condition
●At least one interactive communication
99454 - 16 readings per calendar month
99457 - first 20 minutes of clinical staff time per calendar month
99458 - additional 20 minutes per calendar month
Health Risk Assessment for AWV
G0438 (AWV-I) / G0439 (AWV-S)
The Health Risk Assessment is a mandatory piece of the Annual Wellness Visit for Medicare patients, under general supervision of a physician, containing the following required elements:
●Identify chronic diseases, injury risks, modifiable risk factors, and urgent health needs
●Furnished through an interactive telephonic or web-based program
●Include Medicare's basic framework for patient-centered HRA's
Our Care Coaches spend 40 minutes to an hour with each Medicare patient to accurately collect all data needed for the provider. This Data is then used to create individual care plans for each patient.
The HRA is uploaded to the EHR and the AWV is scheduled by our Care Coaches
Transitional Care Management
99495 and 99496
Care management services during the 30-day period which begins when a physician discharges a Medicare patient from an inpatient stay, with medical decision making of at least moderate complexity during the service period, under general supervision, with the following required elements:
●Communicate with the patient within 2 days of discharge
●Communicate with agencies and community service providers the patient uses
●Educate the patient, family, guardian, or caregiver to support self-management, independent living, and activities of daily living ●Assess and support treatment adherence, including medication management
●Identify available community and health resources
●Help the patient and family access needed care and services
Remote Therapeutic Monitoring and
Chronic Pain Management COMING SOON
The information for all of these is found on CMS.gov
Our Care Management Services Provide
STRUCTURED DATA RECORDING
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Record the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology
CARE PLAN
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Create a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental
(re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues). -
Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record.
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Ensure the care plan is available electronically at all times to anyone within the practice providing the CCM service.
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Share the care plan electronically outside the practice as appropriate.
ACCESS TO CARE
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Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
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Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
MANAGE CARE
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Care management services such as:
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Systematic assessment of the patient’s medical, functional, and psychosocial needs;
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System-based approaches to ensure timely receipt of all recommended preventive care services;
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Medication reconciliation with review of adherence and potential interactions; and
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Oversight of patient self-management of medications.
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Manage transitions between and among health care providers and settings, including referrals to other providers, including:
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Providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or
other health care facilities. -
Coordinate care with home and community based clinical service providers.