Chronic Care Management

Table of Contents:

• Eligibility Rules
• CPT Rates
• Consent
• Add Care Plan
• Manage Care Plan
• Clinical Time Logging
• Approve Time
• Due Reminders

Eligibility Rules:

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• One should have at least two chronic conditions.
• Should have an active insurance.

CPT Rates:

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• There are six CPT codes associated with CCM.
• The details of these CPT codes and their applicable rates are provided below.

Instructions:

• To add CCM, please go to the Patient Dashboard, select the CCM tab, and click the "Add Care Plan" button. The consent screen will then appear.

Consent:

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• If the patient agrees to receive the CCM service, click "Accepted by patient" and submit.

• You can view the Consent in two languages: English and Spanish. By default, English is selected.
• An option is available to upload a file within the content; this step is not mandatory.
• From above the Consent tab, you can access the clinical time clock to review the clinical time and generate a bill.
• To view the Consent in Spanish, select the Spanish language as follows:

• If the patient disagrees, please select "Rejected by patient" and submit.

• Please note that the Edit button is located on the right. You may update the details and select the “Accepted by patient” option once the patient agrees to receive the service.

• You may select the consent date and time manually for prior dates; however, there are restrictions for future dates and times. By default, the current date and time are displayed.

Add Care Plan:

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1. After you submit consent, you will see the Care Plan screen (only when the consent is accepted by the patient).

2. You will see a wizard at the top, with the following sections:

• Diagnosis
• Medications
• Care Questionnaire
• Important CCM Information
• Other Details
• Miscellaneous

3. In the Problem List section, there are fields for Chronic conditions and Allergy. To enter information, please use the Add button located next to each label. After you click the button, the corresponding pop-up will appear.
4. In the pop-up window, use the Search button to locate the relevant condition. Then complete the remaining details and select Add within the Chronic Care Problem, Surgeries, and Test/Procedures pop-ups.

5. To edit the data, hover over the input field to view the Edit and Delete options. When you click the Edit button, a corresponding pop-up will appear. Make the changes you need, then select the Update button. After you have updated the Diagnosis, click the Save & Continue button to proceed to the Medications section.

6. You may view the list of active medications prescribed for the patient. You may also add, edit, activate, and inactivate medicines, as well as delete them.

7. To add medicines, click the "Add Medicine" button on the right. The Add Medication pop-up will appear. To enable a prescription expiry reminder, select the checkbox and choose one of the two options: Remind before 5 days or 10 days. Then click the "Add Prescription" button to save the information and add the prescription.

8. To edit any medicine, click the corresponding Edit button. Once you click the Edit button, the Update Prescription pop-up will appear make the changes you want to update, and then click the Update button.
9. To inactivate any medicine, switch the toggle to the OFF state. The medicine will be inactivated. To activate the medicine again, switch the toggle back to the ON state.
10. Click the Next button after you have completed your changes in the Medications section. The Care Questionnaire section will then appear.

11. Within this section, you will find all the questions. This section is not mandatory to add to the care plan, but you have to answer the goals questions in order to enable the goals section.
12. on click on the accordion the you see that section questions.

• After answering the question, please click on the "Save Changes" button to save the section.
• After saving, the section will be disabled. If you want to make changes, click on the edit button.

13. After completing all required questions in the care questionnaire, select the “Save & Continue” button. The “Important CCM Information” section will then be displayed.
14. Within this section, all questions must be answered. If you do not provide responses to every question, you will not be able to submit the care plan.

15. After you have answered all required questions in the care questionnaire, click the “Save & Continue” button. The “Other Details” section will then appear.
16. Within this section, not all questions are mandatory. You may submit the care plan without answering every question; however, we recommend completing all required fields to ensure the most accurate submission.

17. After completing the questions, please click the “Save & Continue” button. You will then be directed to the Miscellaneous section.

18. After entering the notes, please click the “Add Care Plan” button to successfully add the care plan.

Following up on the Care Plan, you should see a Goals section as shown below.

1. The Goals section includes three areas: a list of goals, a list of options, and a comments field.

2. In the list of goals, you will find all goal questions included in the care plan. In the list of options, you will see the selected options for each question. The comments area is where you can enter your feedback.

3. After you add your comment, click the “Add button”  to save it. Once saved, you can view it in the history.

4. Once you save it, it changes to edit mode where the field will be disabled. If you want to add new or edit, click on the "add" based on the requirements. You can also see the history when you click on the "history", where you can view, edit, and delete the comments.

Following up on the Goals, you will find the Assessment section as shown below.

1. In the Assessment section, there are two sections: FRA and HRA.

2. To add an FRA, click the + Add New button. After selecting it, you will see a list of questions. At least one question must be answered in order to submit the form. Once you submit the form, the added history will appear under the history section.

3. After it has been added, you will be able to view the FRA in the history section. By hovering over the title, you can access the edit and delete icons, from which you can carry out the available actions.

4. When an FRA is added, it will also create a set of notes in the notes section using points based on your answers. In addition, a non-billable record will be generated based on the FRA time, and the FRA will be attached to that record.

5. The same process applies to HRA; however, the only difference is that you will not receive points in the notes for HRA.

• Following up on the Assessments, you have an Activity section as shown below.

• To add an activity, click the “New Activity” button in the top-right corner. The Add Activity pop-up will appear. The Billing Type, Provider, Patient, and Date fields will be auto-populated. Enter the remaining details, then click the “Add” button.

• The added activity will be saved as follows.

Manage Care Plan:

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• After you add the care plan, you will see an upload button that allows you to upload a file. Please ensure the file size does not exceed 5 MB.
• Next, locate the two buttons at the far right: View Log History and View Summary, which appear below the wizard.
• Once the care plan has been added, you may edit and modify any field within any section.
• In the View Log History section, you can access detailed logs of all activities. This includes updates or modifications made by program coordinators/providers, with each entry displaying relevant information such as names, dates, and timestamps. By selecting the designated button, a pop-up window will open, enabling you to review the logs conveniently and download them in A4 format.

• In the Summary view, you will find a comprehensive overview of the CCM service, including the “From” and “To” details. In addition, you may download the summary at your convenience.

• You can also send the care plan by clicking on Send Care Plan. Upon clicking, a popup will appear with an editable email field. By default, the patient’s email address will be prefilled.

Once you click Send, the care plan PDF will be sent via email. This action will be logged, and you can view the history in the Notes section, as shown below.

In the diagnosis section, you will find options to add, edit, and delete chronic conditions and allergies.

• To edit the Diagnosis list, hover over the fields. You will see an Edit icon, as shown below. After you make your changes, click the Update button to save them. Otherwise, click the Cancel button to discard the changes.
• When you click the Edit icon, make the required updates in the Conditions section. Then click the Search button to review other conditions. After making your changes, click the Update button.
• Similarly, to make any changes to Allergies, click the Edit icon and then the Update button to save your changes.
• You can also use the Delete icon. After you click it, you will be asked to confirm whether you want to proceed with the deletion.
• You cannot update the Condition itself—only the Condition details. To add a new condition, go back and click the + icon.

• In Medications, click the Edit icon in the Actions column to edit the medication.

• You will see the pop-up displayed as shown below. Please click the Update button once you have completed your changes.

• In the care questionnaire, you will find an Edit button on the right use it to make the necessary changes.

• Click on the Edit button, you will see the screen as follows, after you make your changes click on the Save Changes Button.

• In the important CCM information details section, click the Edit button to make the necessary changes.

• In the Other Details section, click the Edit button to make the necessary changes.

• Please make your changes and click the Update button. Otherwise, click the Cancel button. You will be prompted to confirm whether you want to discard your changes.

• Activities can be added, but they cannot be edited or deleted.

CCM History:

Upon clicking on the CCM history, you will see a small pop-up model opening next to the button. Here, you can view the care plan enrolment history.

If you would like to discontinue the service, please click the "Discontinue" button located next to the service history. After you select the "Discontinue" button, a pop-up modal will appear, prompting you to provide the reason for discontinuing the care plan.

Currently, the CCM functionality is disabled, preventing any actions such as adding, editing, or deleting entries within the care plan. However, you still have the ability to download view summary reports.

If you would like to resume the service, please click the “Resume Service” button located at the top of the page. After you click it, you will be redirected to a new consent page. Once you accept the content on that page, your entire care plan will be enabled, and the enrollment date will be recorded in the CCM history.

From a clinical time perspective, you can also manually add the bill by clicking the add icon.

• Service - The service will be auto-populated as ccm.
• Activity - Activity will be auto-populated as billing.
• Date - Select to which date you would like to be billed.
• From - select the from time.
• To - select the to time.
• Notes - Add a note that is related to the billing.

When adding the record, it will be saved in the clinical time section.

There are multiple ways to add a bill.

1. From Patient Listing.
2. From Operational Reports.
3. From Patient Dashboard.

4. Manual Log Entry From Clinical Time.

   
   

1.From Patient Listing.

As shown in the above image, when you click on any service CCM in the patient listing, it will show you the pop-up as follows.

If you click on Yes, the timer will start (billing time will begin) and you will navigate to that service in the patient dashboard. If you click No, you will navigate to that particular service in the dashboard without billing.

Billing Flow

• If you select the CCM service and then click Yes to start billing the time, you will be taken to the service with the billing timer set to ON. This action will disable other services, because once you begin billing for a specific service, you are not able to navigate to other services such as PCM, TCM, RPM, or AWV.

  

• If you want to stop the billing, you can click on the STOP icon at the top near the header as follows.

  

• Once you STOP the billing, the other services will be enabled, and the bill will be reflected in the clinical time billing activity section.

  
  

2. From Operational Reports.

Within the patient tab, you will locate the inactive Operational Reports. Please proceed by clicking on the Operational Reports Tab as indicated below.

Beginning at this time, we are able to bill CCM only. Within a record, selecting the MRN number or Patient Name will direct you to the specific patient’s dashboard with the service activated, so you can proceed through the steps in the billing flow.

3. From Service:

If you would like to initiate the billing process while you are on a specific CCM service tab, you may begin billing seamlessly by selecting the Start Billing icon at the top of the page and then following the instructions provided in the Billing flow.

• If you would like to bill the records listed in the Billing section, please select the checkbox at the beginning of each record.

2. You can see an "Add Bill" button on the Top Right of the table. Click on it to show a pop-up for adding a bill as follows.

• Service - The service name will be pre-populated based on the record you selected in billings.

  Note: If you select multiple records with different services, then it will be categorised as "others."

• CPT code: - Select the CPT code based on the billing type.

• Description - Based on the CPT code, you will receive some descriptors from which you can select.

  Note: If the desired descriptor is not available, scroll to the bottom of the dropdown, click on the other option, and enter your desired descriptor.

• Provider - The provider's name will be pre-populated based on the record you selected in billings.
• Patient - The patient's name will be pre-populated based on the record you selected in billings.
• From Date - It will be pre-populated, and the date and time will be based on the oldest record selected.
• To Date - It will be pre-populated, and the date and time will be based on the newest record selected.
• Notes - Add a note that is related to the billing.

• Service Type - It will be pre-populated when you select the CPT code. It is also editable.

  After clicking on Add, the billed records will be disabled. The bill will reflect in the Claims tab.

3. To submit the bill, click on the Bills Tab to navigate to the Bills section.

4. Upon navigating to the Bills tab, select the service type in which you have added the bill from clinical time.

• Note :- If you have added a bill with services other than clinical time, please select the 'Others' tab in the service section of the billing.

Clinical Time Logging:

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1. To view the Clinical Time Logging (Billing) for CCM, go to the Patient Dashboard and click on the Claims Tab. Following screen can be viewed.
2. There are 4 sub tabs - TCM, CCM, RPM and Others, billing logs for each program.

3. Clicking on RPM, CCM, TCM and Others tab, will display claims list with checkboxes for each row with details as follows:

• CPT code
• Time
• From (Date & Time)
• To (Date & Time)
• Topic
• Summary
• Status
• Action

4. CPT codes are different for all types i.e., RPM, CCM, TCM and Others. CPT codes for all reimbursement types are different.
5. Billing Period- From and To date range can be selected in the Billing period to display the bills list between the selected range.
6. Click on CCM tab.

• Users can use the “Add  Claim” option to add a new claim to the provided list by entering the required details, including Service, CPT Code, Description, Provider(Auto-Generated), Patient (Auto-Generated), Month(Auto-Generated), Notes and Call Type.

  

• To edit the call details, click the Edit icon under Action. This allows the user to update the details for the selected Claim in the list, including the Service, CPT Code, Description, Provider, Patient, Month, Notes and Call Type.

  

• Users can select the claim from the list and click Submit. The claim will also be automatically submitted if the appropriate amount of time has passed for that service and its corresponding CTP code.

  

• The submitted bills cannot be edited.

  

• Each reimbursement type tab has filters, as shown:
• All - Displays all CCM call logs.
• New - Shows all newly submitted calls/bills, represented in blue.
• Submitted - Shows all submitted calls/bills, represented in light green.
• Rejected - Displays all rejected calls, represented in red.
• On-Hold - Displays calls that are currently on hold, represented in amber.
• Approved - Displays all approved calls, represented in green.
1. In the Action column, users can view two options: Edit and Delete. The Edit and Delete icons are enabled for all New and Rejected bills.
2. After a bill is submitted, or when it is kept on hold and then approved, the Edit and Delete icons will be disabled.

3. When a user clicks a Rejected call/bill, the user can review the rejected reasons. The details include the rejection date along with the corresponding rejected reason.

   
   

• When you click the download icon, you will be able to access the Summary of the CCM Episode. In addition, you may download the document by selecting the floating download button, or use the print button to generate a PDF for printing.

• we can also download the each bill document by clicking on the download icon.
• we can also download the bulk bill document by clicking on the Download Supporting Documents Button.

Approve Time:

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• The call logs that are submitted are saved in the Billing Portal. Once the Admin logs in, they can view the screen shown below.
• By default, All Programs and All Providers are selected. You may adjust these options based on your preferences.

• On the dashboard, count for Patients enrolled, Patients billed, Bills accepted, Bills pending will be displayed.

• On the left-hand side, there is a table icon. Upon clicking on it, a pop-up will appear where you can select the required table columns, as shown below.

  

  

  
  
• There are 9 filters: Network, Center, Service, Provider, Claims Status, Payment Status, CTP Code, Duration, and Search Bills, which allow you to search bills for review.
• Users can filter the submitted billing list based on the bill status across four categories.
• Submitted Bills
• Bills on Hold
• Accepted Bills
• Rejected Bills
• Patients that qualify under the rules engine for the set of rules associated with the respective CPT code will be ready to be billed, while patients that do not qualify under those rules will be rejected by the rules engine.
• Users can also filter the submitted billing list based on the type of billing or product (All/RPM/CCM/RTM/TCM/PMPM).
• Click the Status filter, select the Submitted Bill option, then click the Program filter and select CCM. The following screen will be displayed.

• User can filter the submitted billing list based on the selected duration of Date from and Date to. We can view the bills based on the Duration type - Monthly, Quarterly & Custom. By default, we have Monthly selected.

  

• Users can filter the submitted billing list by provider name for the selected center.
• The search field is available on the dashboard to find the required data.
• Below the filters, the table is displayed with the following headers:
  • Checkbox — to select all records
  • Patient EMR ID
  • Patient Name
  • Date of Service — the date on which the service was provided
  • CPT Type — RPM/CCM/TCM/Other CPT code and topic
  • Note — meeting notes captured while scheduling
  • Provider Name
  • Bill details — Bill ID and the month, date, and year the billing was submitted
  • Actions — Approve / On Hold / Reject
• All submitted bills appear in the list in checkbox form. Users can select bulk actions to mark the selected bills as Approved or Rejected. Users can also download the bills by clicking the Download option.
• To submit the bills, select the checkbox and click Accept selected bills on the right. A pop-up will appear to confirm whether you want to accept the bill. Click Yes to accept the bill.

• You can also reject bulk bills by selecting the relevant records and clicking the "Reject selected claims" button. This button will be displayed in the header area once you select the bills. After you click the button, a pop-up window will appear prompting you to enter the reason for the rejection. Once you enter the reason, click Submit. The rejected bills will then be listed under Rejected Bills.

  
  

  

  
  

• You may perform actions—Approve, On Hold, or Reject—for individual calls. After the call log is approved, set to On Hold, or rejected, it will be categorized as Accepted, On Hold, or Rejected, respectively.

  

• If there are no calls logs, you will see an empty state showing No records found.

  

  
  
• Once the bills are accepted, you can view them by selecting Status as Accepted.
• To download the Bill report, select the checkbox for an individual record, or select the checkbox in the header to download the report for all records.
• You can download the report for any status, including All, Ready to bill, Submitted, On-Hold, Rejected, and Approved.

• You can view download option at the right, click on the download to download the report. You can view it in your downloads.

• We can also add the Billed Amount, Allowed Amount, Adjusted Amount, Balance Amount for each bill in the input field where you can enter the amount and click outside the field. It will be saved, but it is only for reference and will not be referenced anywhere else.

  

• We also provide the options Claim Denied, Claim Failed, Closed, Patient Pending, Secondary Pending, and Claims On Hold to update the payment status of each claim. To access these options, please select the submitted claim status and click the more icon, as shown in the image below.

• We also have the option to upload the billing reconciliation file. You can upload an Excel file with the claims data of each patient and check the history of the uploaded file. Additionally, you can download a sample file or sample reconciliation template by clicking on the "Download Reconciliation Template" button.

  

  

Note:

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Due Reminders:

CCM – Monthly Call Due:

If the difference between the last billable CCM clinical time date and the current date is greater than 30 days, clinical time can be added.

CCM – Medication Reconciliation Due:

If the difference between the last added or updated medication date and the current date is greater than 90 days (one quarter), closing this alert will add 5 minutes of clinical time.

Once you click on the Complete Medication Reconciliation button, a popup will appear where you can add notes. These notes will be attached to the clinical time record.

CCM – Care Plan Update Due:

If the difference between the last care plan added or updated date and the current date is greater than one year, the care plan can be edited. No clinical time will be added.

CCM+ – Chart Review Due:

This alert appears when RPM is discontinued while the device is still assigned and active, and the CCM service is active. Closing this alert will add 5 minutes of clinical time.

Once you click on the Complete Chart Review button, a popup will appear where you can add notes. These notes will be attached to the clinical time record.

FRA Due:

If the difference between the last FRA added date and the current date is greater than one year, adding or editing the FRA will resolve the alert. No additional clinical time will be added.

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