Care Plan is a requirement for CCM and PCM billing
CMS strongly suggests in their documentation that a care plan be formulated for an RPM patient, but does not explicitly require one for billing.
For CCM, the initial care plan creation can be billed (G0506) at the same time as the initiating E/M visit. The code G0506 is specifically designated for CCM and can not be billed separately.
PCM initial care plan creation does not have an associated code.
Patient Care Plan Basics
Care planning is a vital component of Chronic Care Management and Principal Care Management. Here are the basic requirements:
A patient-centered, electronic care plan based on a physical, mental, cognitive, psycho-social, functional, and environmental (re)assessment, and an inventory of resources.
The patient and/or caregiver must be provided with a copy of the care plan.
The electronic care plan must be made available and shared timely within and outside of the practice to individuals involved in the patient’s care.
A comprehensive plan of care typically includes, but is not limited, to the following:
Problem list
Expected outcome and prognosis
Measurable treatment goals
Symptom management
Planned interventions to be taken and identification of the individuals responsible for each intervention
Medication management
Laboratory results and appointment needs
Interaction and coordination with outside resources, practitioners, and providers
A description of how services of agencies and specialists outside the practice will be directed/coordinated
Schedule for periodic review and, when applicable, revision of the care plan
Care Plans can be created a variety of different ways – in the EHR, in ChronicCareIQ, manually using a software template (such as a word document), or other Care Plan Building tools. CMS does NOT stipulate where they must be made. CMS allows care plans to be housed in the EHR or the care management software. Many clients opt to store Care Plans in BOTH their EHR and ChronicCareIQ to meet billing and patient-access requirements.
CCM Care Plan requires 2 or more chronic conditions (not all must be included)
PCM Care Plan is for 1 or more condition (disease-specific) followed by a specialist
RPM Care Plan is for 1 or more condition for remote monitoring – suggested by CMS, not stated as required (ChronicCareIQ recommends as a Gold Standard that a patient has an RPM plan of care)
APCM Care Plan is required for value-based care monitoring
General Care Plan Samples
A care plan can be created using a variety of different software, templates, or systems. CMS does NOT stipulate how a care plan is created (in EHR, in ChronicCareIQ, in a word document) – only that one is required to be made in order to bill CCM, PCM, or APCM.
Some generic Care Plan Templates below give users a general guide to manually-created Care Plans. These are simply guidelines to help clients develop a care plan template that works for their practice and workflow:
Care Plan Examples in CCIQ
Care Plan Code Triggering in CCIQ
G0506 – this is the one-time initial care plan creation code for CCM. CCIQ will drop this code when the initial care plan is uploaded or marked as “Hosted in EMR” under the patient’s care plan tab. A green check mark will appear once the care plan is loaded:
Complex CCM 99487 and 99489
99487 and 99489 codes are for extensive time spent on CCM patient care (60 min and up to two additional 30 min) and for revising or replacing care plans. If a care plan action of “review” or “replace” during the month is taken in CCIQ and the patient has qualifying time accrual, then 99487 and 99489 will drop and replace the base CCM codes 99490 and 99439.
The care plan review or replace action is required for these codes to trigger, as this is the clinical staff’s documentation and attestation that a substantial revision or replacement of the care plan was done in that month. This must be paired with over 1 hour and 30 min of time in a patient chart:
NOTE: As of Jan 2024, the three base CCM codes (99490, 99439, 99439) at 60 minutes pay out MORE on the national average than the 60 min complex code 99487. For this reason, ChronicCareIQ billing optimization engine will not drop complex codes until the 1 hour 30 min mark. This software billing optimization was done for revenue optimization.