412 ||||||||||| APPENDIXES CPT copyright 2015 American Medical Association. All rights reserved. Appendix B Figure B-7. Care Plan Oversight Encounter Worksheet See www.aap.org/cfp for an online version of this worksheet (access code AAPCFP21). 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: _______________
Previous Page Next Page