Defining Care Coordination via Standard Codes

There is not a standard way that organizations track Care Coordination, rather, individual methods are used. We recommend connecting with staff in your organization familiar with how care coordination is tracked which can provide guidance in how to pull this information from your system. 

Other information that may be helpful:
  • Health Care Home clinics differ in how they gather care coordination data and how they seek to cover their CC costs. See MDH's Health Care Homes Incentives & Payments site.
  • Some certified Health Care Homes use the HCPCS codes S0280 and S0281 with modifiers if billing HCH care coordination to DHS/Minnesota Health Care Programs.  Very few certified Health Care Homes are utilizing these billing codes (citing complicated, burdensome and low reimbursement).
  • CMS related codes: Chronic Care Management Services and Transitional Care Management (CPT codes 99495 and 99496) --> Note- CCM and TCM services do not directly correspond with HCH care coordination patient data as many receiving care coordination may not qualify for these specific services
  • Some clinics utilize their problem list to identify and track patients in care coordination. There is no standardization in how that is done so each organization utilizes their own methods for querying the data.
Creation date: 6/22/2021 4:43 PM      Updated: 7/7/2021 9:25 AM
This category is for information related to the MNCARES project.