PDMC

Procedure Name:	Provider Employment Policy – PDCM	SOP #:1	1
Department:	Operations	Revision #:
Employees Affected by Role:	Providers – physicians and APPs	Implementation Date:
		Date Last Updated:
SOP Owner:	HR	Approval Date:

Standard Operating Procedure

Purpose

 To provide clarity on the employment duties and obligations of providers (physicians and APPs) as it related to PDCM.

 

Scope

This applies to all providers (physicians and APPs).

 

Policies and Procedure

1.       Eligibility for PDCM

·         PDCM services must meet the following criteria:  

o    The services are medically necessary and individualized to the patient's condition.  

o    The services require clinical staff time and engagement under the direct supervision of the physician. 

§  Direct Supervision means that the physician must be physically present in the office or clinic and readily available to assist, although they do not need to be present in the same room as the patient when the service is provided.  

§  In December 2024, CMS extended for another year (ending December 31, 2025) the exception implemented during COVID that broadens the definition of direct supervision to include audio/visual and not just “in suite.”  

o    The physician must initiate the care plan, participate in care plan oversight and management, and review/update the care plan.   

 

3.            Patient Engagement & Care Coordination 

• Providers will actively participate in identifying eligible patients for PDCM services, explaining the care model to patients, and obtaining written consent. 

• Providers will work collaboratively with the patient to develop, implement, and adjust a personalized care plan that addresses their chronic conditions and health goals. 

 

4.            Documentation Requirements 

• Providers will accurately document the time spent providing PDCM services, including the date, time, service description, and credentials of the staff involved, in the patient’s medical record. 

• Providers will ensure that all care plans and updates are documented in the patient's electronic health record (EHR) and provided to the patient. 

o    Initial Visit for Month 

§  Documented using short list CPT codes as follows: 
 

5.            Ongoing Monitoring and Adjustment 

• Providers will participate in regular follow-ups with patients to monitor progress, solicit feedback, and make necessary adjustments to care plans based on the patient’s changing condition or treatment preferences. 

• If an initial care plan for the month was created under a particular ICD-10 code, work for the month should be continued in relation to that same ICD-10 code unless all goals have been met and condition is well controlled. 

o    If all goals are met and condition is now well controlled, please repeat documentation requirements for initial care plan. 

• Ensure that continuous patient education and support are provided to encourage self-management and effective health monitoring. 

o    Subsequent Visit for Month 

§  Documented using short list CPT codes as follows: