Achieve Optimal Wellness with SunShine Care Management

A

Illness or disease that typically develops suddenly and lasts only for a short period of time, often only a few days or weeks. Acute conditions are usually caused by a virus or an infection, and sometimes result from an injury or the misuse of drugs or medications. 

Additional information: NOCA : https://www.ncoa.org/blog/chronic-versus-acute-disease/

As a Medicare service, a brief behavioral counseling and intervention for patients who have some indications of alcohol abuse or misuse. Alcohol abuse counseling can be provided through a primary care provider under HCPCS G0443.

Additional information: Medicare Interactive 

A yearly visit with a primary care provider or specialist to create or update the patient's personalized prevention care plan. The annual wellness visit (AWV), which is covered by Medicare, focuses on the patient's current health status and risk factors to create a prevention plan that will slow the progressions on chronic disease. The AWV is billable under HCPCS G0438 and G0439. 

Additional information: CMS | CMSHHSgov YouTube | Physicians Practice

A non-invasive and painless ultrasound of the abdominal aorta that uses high-frequency sound waves to view the main blood vessel (aorta) leading away from the heart. Billable as a preventive service under CPT 76706. 

Additional information: John Hopkins Medicine

Members of the healthcare team who assist and support practitioners in caring for patients.

In general, a care delivery model that integrates behavioral healthcare into the standard primary care setting and takes into account the "whole-person" approach, creating a patient-centered medical home for the patient that can also recognize and treat behavioral health concerns. As a Medicare Service, BHI is a billable form of chronic care management (CCM) where a patient receives care management for a behavioral health condition which is also assessed each month using a validated rating scale.

Additional information: Integration Academy

Someone who receives government benefits (e.g., Medicare, Medicaid), because they have met certain qualifying conditions, such as income and asset guidelines.

Additional information: CMS: https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/Beneficiary-Services/Overview

Monitoring fluctuations in blood pressure levels through the use of a blood pressure monitor device (such as a sphygmomanometer). Typically used for treatment of hypertension and other cardiac conditions.

Additional information: Heart.org: https://www.heart.org/-/media/files/about-us/policy-research/policy-positions/clinical-care/remote-patient-monitoring-guidance-2019.pdf

A way to connect one or more devices to each other, allowing them to work and communicate with each other using Bluetooth wireless radio technology.

Additional information: https://www.scientificamerican.com/article/experts-how-does-bluetooth-work/

Measurements that indicate the levels of bone mineral density within the patient's bones. Measurements are then typically compared to an established norm to calculate a bone density mass score. As a Medicare service, bone mass measurements can be performed via CT scan, X-ray or ultrasound under CPT codes 76977, 77078, or 77081-77085.

Additional information: NIH: https://www.bones.nih.gov/health-info/bone/bone-health/bone-mass-measure

Visits with a practitioner that focus on a patient's heart disease and risk factors for developing it. Cardiovascular risk counseling places emphasis on preventing, treating, and addressing conditions, such as high cholesterol, high blood pressure, family history, or diabetes, and encourages lifestyle modifications. Billable as an annual Medicare preventive service using HCPCS G0446.

Additional information: Stanford Healthcare: https://stanfordhealthcare.org/medical-treatments/c/cardiac-behavioral-counseling.html

The provision of quality care over time through ongoing healthcare management with the entire medical care team, leading toward the shared goal of high-quality, cost-effective medical care.

Additional information: PubMed

The sharing and organization of all patient care activities among all care team members to achieve safer and more effective care.

Additional information: AHRQ

Care management services are patient-centered management and support services that may be provided by clinical staff under the direction of a physician or provider. These services generally include the ongoing management of a patient care plan, care coordination, and patient education. Chronic care management, remote patient monitoring, transitional care management, and behavioral health integration are examples of care management services within Medicare.

Additional information: AHRQ

Within remote patient monitoring, a form of remote connectivity that utilizes a mobile cellular network (e.g., 2G, 3G, 4G LTE) to monitor performance and receive measurements from a connected medical device.

A care coordination service model that reimburses practitioners for non-face-to-face care coordination activities. Chronic care management (CCM) includes the provision of patient education, care planning, medication management, and care coordination. Most often billed under CPT 99490 and 99439.

Additional information: CMS | Physicians Practice

Chronic conditions are diseases or illnesses that last one year or more and require ongoing medical care, limit the patient's activities of daily living, or both. Commonly recognized chronic conditions include heart disease, cancer, and diabetes.       

Additional information: CDC

Staff members who work under the supervision of a physician or other qualified healthcare professional and who is permitted to perform or assist in the performance of a specified professional, clinical service.

Additional information: APPC

A software structure wherein the service provider maintains control over the software and can restrict access to users or content. Also referred to as a walled or closed ecosystem.

An evaluation conducted by a qualified health professional that evaluates a patient's level of maintained or remaining skill in the areas of learning, memory, judgement, and reasoning.

Additional information: NCBI

Testing of a patient's cognition capability, including thinking, memory, language, judgment, and ability to learn new things, to determine whether there are problems with one or more aspects.

Additional information: AAFP

Formal relationships or agreement between physicians, pharmacists, or other providers that allow for the collaborative expansion or extension of services between the participants. Collaborative practice agreements (CPAs) define patient care functions among participants.

A variation of CCM, complex chronic care management (CCM) is for patients with two or more qualifying conditions who require more clinical staff and physician time. Complex CCM is billed under CPT 99487 and 99489.

Documents created and maintained by an interdisciplinary care team that outlines specific and actionable patient care information for clinicians and staff across multiple care settings.     

Additional information: CDC

Linking of any electronic tool (e.g., computer, tablet, smartphone) to the Internet which enables it to communicate with other tools also attached to the network.

Additional information: IOT Evolution

A combination of software and hardware that provides a means of delivering a message to recipients — often concerning the activity on an account — that provides the user to ability to modify rules dictating the delivery, such as timing, frequency, and type of information delivered.

A series of questions or tests that helps practitioners identify symptoms of the mood disorder often associated with feelings of sadness, loss, or anger (i.e., depression) in patients. Billable under Medicare as an annual preventive service via HCPCS G0444.

Additional information: Medline Plus

In a medical office setting, the presence of a physician in the office, although not necessarily in the room, and immediately available for assistance to members of the healthcare team when a service is performed to or on a patient.

Additional information: Advisory

The process of checking a patient's active insurance coverage and whether such coverage extends to specific services.

A means of adding "cellular connectivity" (see definition above) to a product in which the technology that provides such connectivity is built into the device.

The fecal occult blood test (FOBT) is a lab test used to check stool samples for hidden (occult) blood.

Additional information: Mayo Clinic

Outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid. They provide a set of comprehensive, high-quality primary care and preventive services regardless of patients’ ability to pay.

When a service is delivered or furnished under a Physicians overall direction and control but does not necessarily require their physical presence during the delivery of service.    

Additional information: Advisory

The process of collecting patient health information and biometric testing to assess a patient's current health status and risk factors for developing chronic disease or illness.    

Additional information: The Commonwealth Fund

A device that monitors cardiac events, including heart rate and rhythm. Typically used when a patient requires long-term, ongoing monitoring of activities and possibly symptoms that occur less than daily.

Meeting the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the federal law that requires the protection and confidential handling of protected health information and identifies industry-wide standards for healthcare information on electronic billing and other processes, among others.

Additional information: CDC

The system through which Medicare beneficiary eligibility data is released to Medicare trading partners for use by providers or other authorized billing agents. It is used to prepare accurate Medicare claims, determine beneficiary liability, and check eligibility for specific services.

Additional information: CMS

Commonly known as the "Welcome to Medicare Preventive Visit," IPPE is a service for newly enrolled Medicare beneficiaries that places emphasis on health promotion and disease prevention and detection. The IPPE is billed under HCPCS G0402.

Additional information: AAFP

As defined by the Centers for Medicare & Medicaid Services: a conversation occurring in real time that includes synchronous, two-way interactions that can be enhanced with video or other kinds of data. Interactive communication is a requirement for care management services such as chronic care management and remote patient monitoring.

A discussion between a patient and provider to discuss the risks and benefits of performing a low-dose CT lung cancer screening on patients with a history of tobacco use. Billable whether or not a CT scan is actually performed under HCPCS G0296.

Additional information: ACR 

A bipartisan legislation signed into law in 2015that created the Quality Payment Program. Among its key purposes: repeal the sustainable growth rate formula; change the way Medicare rewards clinicians for value over volume; streamlines multiple quality programs under the new Merit Based Incentive Payments System (MIPS); deliver bonus payments for participation in eligible alternative payment models (APMs).

Additional information: CMS

A healthcare delivery model intended to manage cost, utilization, and quality.

Additional information: Medicaid

In remote patient monitoring, a day where at least one remote physiological measurement has been taken by the patient enrolled in RPM. Measurement-days are used to determine eligibility for the RPM CPT 99454.

Broadly speaking, any device used for medical purposes. Within remote patient monitoring, equipment used to collect health data from patients and electronically transmit that information to healthcare providers for assessment and recommendations.

Additional information: FDA

The coordination and delivery of care services and activities designed to help Medicare patients manage their health, with the principal goal of improving patient health and wellness.

Additional information: CMS

Services and/or screenings that a Medicare recipient may be eligible to receive based on predetermined eligibility and health status requirements. Such services typically include vaccines for flu and pneumonia, cardiovascular screening, and diabetes screening.

Additional information: CMS | Practical Cardiology | Physicians Practice

A temporary measure enacted by Medicare to make the delivery and coverage of telehealth services easier during the COVID-19 public health emergency. This extended the use of telehealth services by stating that the originating site — where the patient is located at the time of service — does not need to be in a rural health professional shortage area and expanding the list of approved originating sites to include the patient's home.     

Additional information: CMS | Physicians Practice

One or more services intended to optimize therapeutic outcomes for patients. Also: A complimentary, patient-centric program offered through Medicare Part D plans to select members designed to help improve medication use so members can better manage their chronic conditions and improve overall health.

Additional information: CMS

A confidential analysis conducted by a practitioner that evaluates the mental health status of a patient. The assessment addresses the patient's ability to think, reason, and remember as well as evaluate the patient's mood and behavior.

Additional information: Medline Plus

A slight but noticeable decline in cognitive abilities, including memory and thinking skills, past what is considered normal due to age.    

Additional information: ALZ 

A track under the Quality Payment Program that moved Medicare Part B providers to a performance-based payment system. Under the system, eligible clinicians have their performance scored and can receive a payment bonus, a payment penalty, or no payment adjustment.

Additional information: QPP

A licensed healthcare professional who offers healing services different or separate from those provided by a physician. Typically, the practice privileges of non-physician providers are limited, and many have no prescribing authority in most states. Non-physician providers include midwives, nurse practitioners, optometrists, physician assistants, physical and occupational therapists, psychologists, social workers, and chiropractors.  

Additional information: Noridian Medicare

Service that promotes sustained weight loss in patients through interventions concerning diet and exercise. Behavioral counseling for obesity is a billable service under Medicare using HCPCS G0447.

Additional information: Medicaid 

The evaluation by a practitioner of a patient's likelihood of misusing opiates, both recreational and medicinal.

Additional information: NCBI 

The act of a patient approving receipt of care services, usually obtained after a patient is provided relevant information and ensuring their understanding regarding health and risk factors as well as the potential risks and benefits of services. Consent should be documented.   

Additional information: NCBI | AMA-ASSN

Established and subsequently maintained during annual wellness visits (AWVs), a service that focuses on care plan development, established by a practitioner that outlines the steps necessary to best maintain the patient's health and prevent the further onset of chronic health conditions.   

Additional information: CMS 

A screening guide developed in collaboration between a patient and practitioner outlining the patient's recommended schedule for screenings and other suggested preventive care services.

Additional information: Medicare 

The comprehensive listing of maximum fees used by Medicare to reimburse physicians for covered services on a fee-for-service basis. Undergoes annual updates.

Additional information: CMS 

Routine healthcare intended to prevent patient illnesses, disease, or other health problems. Includes a mix of screenings, checkups, and counseling.

Additional information: Healthcare 

The independent, volunteer group of national experts in prevention and evidence-based medicine tasked with providing federal recommendations about clinical preventive services, such as screening tests, counseling services, and preventive medications.

Additional information: US Preventive Services Task Force | AHRQ

A service that provides additional care to patients with one or more chronic conditions by focusing care solely on one such condition. Like chronic care management, principal care management offers an avenue of reimbursement to physicians for the additional work they do while caring for high-risk, complex patients. Examples include medication reconciliation and adjustments, creating a care plan, and patient follow-up.

Additional information: CMS 

When delivery of a preventive service by a practitioner requires an extended period of patient contact that goes beyond the typical timeframe. Prolonged/additional time spent provider a qualifying preventive service can be billed under HCPCS G0513 and G0514 (in addition to the code for the preventive service itself).

A licensed or non-licensed healthcare professional with proficient skill and experience who performs a professional service within his/her scope of practice and independently reports the professional service.

Additional information: AAPC

An incentive program required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA to replace the payments from the Sustainable Growth Rate formula. Clinicians can participate in the Quality Payment Program via the Merit-based Incentive Payment System (MIPS) or advanced alternative payment models (APMs). 

Additional information: CMS

The use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions. RPM allows providers to continue tracking healthcare data for patients once they are discharged. It also encourages patients to take more control of their health.

RPM is covered under Medicare and many other public and private insurers under CPT 99545, 99457, and 99458.

Additional information: CCHPCA | Beckers | Physicians Practice | Medical Economics | Physicians Practice

Another term used to describe remote patient monitoring. Frequently used by federal agencies (e.g., CMS).

A regular — typically annual — review and assessment of a patient's physical health and wellness. Medicare does not cover a routine physical exam.

Additional information: Medline Plus 

A program intended to increase access to primary care services for patients in rural communities. RHCs can be public, nonprofit, or for-profit healthcare facilities. The main advantage of RHC status is enhanced reimbursement rates for providing Medicare and Medicaid services.

Behavior therapy and guidance provided by a qualified health professional that focuses on stopping patient tobacco use. Billable under Medicare using CPT 99406 and 99407.

Additional information: NIH 

A clinical test that measures the air capacity of the lung. Used to diagnose conditions such as asthma, chronic obstructive pulmonary disease (COPD), others that affect breathing.    

Additional information: Mayo Clinic 

An itemized list of physician charges that reflects services provided to a patient.

Use of electronic information and telecommunication technologies to provide care when a practitioner and patient are not in the same place at the same time.

Additional information: Telehealth | Becker's

A temporary modification to the rules for delivering covered telehealth services that was enacted during the COVID-19 public health emergency. Such waivers were issued by the federal government (i.e., CMS) and some state governments. See also: "Medicate telehealth waiver."

Use of electronic information and communications technologies to provide and support care delivery when distance separates the practitioner and patient.

Additional information: Health IT 

Concerning care delivery, the documentation of the amount of time spent on patient care activities, both directly and indirectly.

Management of care as patients move out of (i.e., discharged) an inpatient or other setting to help ensure there are no gaps in care and reduce the likelihood of readmissions. Qualifying patients are typically those with medical and/or psychosocial problems requiring moderate- or high-complexity medical decision-making.

Additional information: AAFP

The process through which a practitioner best ensures patients comply with recommended immunization schedules.

Additional information: CDC 

Means of keeping track of patient weight fluctuations to mitigate and avoid a patient health crisis. Usually performed with a scale, with some connected technologies capable of providing the practitioner with real-time updates.

A review of a Medicare beneficiary's medical and social history related to health and education and counseling about preventive services. Beneficiaries are eligible to receive the visit upon enrollment in Medicare, with the visit covered once within the first 12 months that a patient is enrolled in Medicare Part B. Patients leave this visit with a written plan outlining which screenings, vaccines, and other preventive services they will need and when. Billable under HCPCS G0402.

Additional information: Medicare