Chronic Care Management (Ccm)

CHRONIC CARE MANAGEMENT (CCM)

PROGRAM CHECKLIST TOOL

ICAHN – IRCCO DEVELOPED TOOL

(Original version: 2/1/17)

PROGRAM PREPARATION

Practice setting can provide and bill for CCM services:

Practice does not participate in CMS sponsored model or demonstration program thatalready includes payment for CCM (such as MAPCP or CPCI)

 Verified with Medicare Administrative Contractor (MAC)as qualified to bill for CCM services

Care team has been assembled:

Care coordinator identified (if applicable)

 All team members assigned roles and responsibilities

Providers/practitioners identified and educated on CCM program elements

Electronic Health Recordis in place:

 Meets current CMS certification criteria and standards

 Has capability to capture patient demographics, problem lists, medications, allergies

Contains care plan and/or can upload copy of patient care plan into it (if applicable)

Process is in place to build patient-centered comprehensive care plan:

Process identified for completion—who, what, where, when, how

 All elements to include in care plan identified (per CMS regulations)

Able to format electronically

Process to transfer into electronic program (if utilizing paper copy)

Able to upload copy into EHR (if built outside EHR)

Process identified to provide copy of care plan to patient

All team members educated on format and process

Process is in place to provide patients with 24/7 access to care:

Identified process for during business hours

Process in place can address patient’s basic needs

 Process in place can address patient’s urgent needs

Identified process for after business hours

On-call program in place / contract on-call withthird party (ER or other)

Process in place for on-call party to access patient information

Process in place can address patient’s basic needs

Process in place can address patient’s urgent needs

Access to practice provider for patient’s urgent needs

Process in place to log & communicate on-call information back to provider

Process to ensure patients receive successive routine appointmentsis outlined:

Scheduling/front office staff included in education on this process

Process to complete patientcare transitions is outlined:

Tool/process to create “Continuity of Care” (CCD) document in place

Process identified for sharing CCD & care plan with other healthcare providers

 Process outlined to implement TCM protocol when applicable after inpatient discharge

Method is in place for enhanced communication with patients:(other than via telephone)

 Established one or more of the following:patient portal, emailing process, secure internet messaging system, other

Patient consent process is outlined:

 Patient consent form created and available to all staff (if utilizing consent form)

 Required elements and steps for patient consent identified/ resource available

All CCM program toolsare identified and developed: (if applicable)

Tool to track target patientswho qualify for CCM & includes risk stratification

Tool to track each requirement met and patient eligibility for CCM services

Tool to organize and track monthly CCM activities for each patient

Tool to track that CCM services are billed each month

Tool or program developed to create patient-centered care plans

Consent form developed (if utilizing consent form)

Tool to trackTCM services when utilized for CCM patients & track billing for TCM

Billing process is established:

 Billing staff educated on CCM services and how to bill for co-pays

 Billing staff has resource list of allowable CCM codes and if eligible to bill each code

• RHC/FQHC have limited code use

 Billing staff educated on which forms to use for CCM billing

 Billing staff has established communication method with care team staff to know when to bill for CCM services each month and for which patients

Educational needsare outlined and performed: (quick review)

 Front office/check-in staff educated on CCM and their roles

Staff knows how to identify active CCM patients and care team members

Staff understands CCM forms utilized and when to give to patients

Staff knows to always schedule CCM patients with same provider

Staff can identify when to collect patient co-pays for CCM

 Care team all understand CCM program service elements

Educated on all tools, technology, and services utilized

Care coordinator fully knowledgeable on role/duties

 Billing staff educated on CCM services

Billing staff understands all CCM service codes available and which codes can be used in this practice setting

Billing staff understands how to bill for CCM, what forms to use, and how to communicate with care team to initiate monthly billing

PATIENT READY TO PARTICIPATE

 Patient targeted for CCM has 2 or more chronic conditions that meet CMS guidelines

“Risk Stratification” tool identifies higher need for CCM /patient isplaced on final CCM target list

Patient’s insurance coverage for billed CCM servicesis verified / secondary to cover co-pay:

 Primary insurance covers CCM Primary does not cover CCM

 Secondary insurance covers co-pay Secondary does not cover co-pay

 Determinationis made that patient needs/does not need appointment with provider:

NEEDS: Brand new patient or established patient not seen in last 12 months

DOES NOT: Established patient, had AWV, IPPE, or E/M level 2-5 in last 12 months

 Paperwork prepped and sent to patient for completion

AWV, IPPE, E/M level 2-5, or TCM (if in TCM time frame) is scheduled

OR

 No appointment is necessary, patient/caregiver is calledand informed about CCM services:

All CMS required elements of CCM services discussed with patient/caregiver

Patient/caregiver offered enrollment into CCM services program

 Patient accepted enrollment into CCM Patient refused enrollment into CCM

Documented in patient’s medical record—all required elements, acceptance/refusal

Patient consent form is signed and uploaded/filed in patient’s medical record: (if form is utilized)

 Patient has legal guardian / consent form signed by legal guardian and filed

Copy of any legal paperwork is obtained and placed/uploaded in patient’s medical record:

POA, DNR, Guardianship, Advanced Directives, POLST, other

Verificationis made that patient is not receiving CCM services from another provider

Patient is educated and provided all access information:

Patient educated on co-pay responsibility (patient to pay/secondary covers)

24/7 access process—gave phone numbers for business and non-business hours

Patient set up/educated on patient portal, electronic systems, other access info

 Patient able to participate in cell phone and internet interactions (if uses)

Patient understands monthly phone calls with care team / times scheduled

Patient understands care transition process & CCD/Care plan will be shared

Patient-centered care plan is completed electronically, following all CMS requirements:

Patient given copy of care plan

Copy of care plan entered/uploaded into HER

 All care team members and other healthcare providers given access to care plan

 EHR for patient contains all required elements (demographics, meds, allergies, problem lists)

Patient is placed on active CCM services list/ added to care team schedules and calendars:

 Care team scheduling updated and has access to CCM list

All care team schedules/calendars with patient’s dates/info completed

 Patient’s name added to spreadsheets, tools, tracking forms

Patient’s routine appointments are scheduled in advance with same provider / patient is informed:

 Patient reminders for appointments set up in system/added to schedules

Patient is ready and prepared to participate in monthly CCM services

Page | 1