Appendixes
CPT copyright 2017 American Medical Association. All rights reserved.
IV. Care Plan Oversight Encounter Worksheet
Care Plan Oversight Encounter Worksheet
See www.aap.org/cfp for an online version of this worksheet (access code AAPCFP23).
Physician: _________________________________________ Patient Name: __________________________________
Services Provided:
The letter that corresponds with each service provided should be placed in column #2.
A. Regular physician development and/or revision of care plans
B. Review of subsequent reports of patient status
C. Review of related laboratory or other studies
D. Communication (including telephone calls not separately reported with codes 99441–99443) with other
health care professionals involved in patient’s care
E. Integration of new information into the medical treatment plan and/or adjustment of medical therapy
F. Other (Attach additional explanatory materials on the services provided.)
Date of ­
Service
XX/XX/XXXX
Services ­
Provided
Contact Name
and Agency Start Time End Time Total Minutes
Monthly
Subtotal
Explanation for additional services provided:
Date:_______/_____________________________________________________________________________________
_________________________________________________________
Date:_______/_____________________________________________________________________________________
________________________________________________________
Date:_______/_____________________________________________________________________________________
________________________________________________________
Time Requirements per
Calendar Month
Patient in Home, Domiciliary,
or Rest Home (eg, assisted
living facility)
Patient Under the Care
of a Home Health Care
Agency
Hospice
Patient
Nursing
Facility
Patient
15–29 min 99339 99374 99377 99379
≥30
min
99340 99375 99378 99380
≥30
min Medicare code
G0181 G0182
Monthly Total: ________________ CPT® Code: _______________
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