Remote Preventative Care Management Services

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:​

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• 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​

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With the RPCM Platform, Registered RN 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 the Care Coaches. 

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Applicable CPT Codes

• G0438 (AWV-I) 

• G0439 (AWV-S)

Care management services for patients with 2 or more chronic conditions, under general supervision, with the following required elements:

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• 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​​

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Applicable CPT Codes

• 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

Care management services for patients with 1 chronic condition expected to last at least 3 months, under general supervision, with the following required elements:

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• 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

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​Additional CPT Codes:

• 99426 - first 30 minutes of clinical staff time per calendar month

• 99427 - additional 30 minutes per calendar month

​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:

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• 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

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Applicable CPT Codes:

• 99484