Mandatory Escalation Triggers
From Companion SOP (Section 2). Every protocol must enforce these — they are not negotiable per provider.
- ⚠MSK Pain score ≥ 8/10 → Tier 2 NP
- ⚠PHQ-2 ≥ 3 (positive depression screen) → Tier 2 NP
- ⚠Suicidal ideation → Emergency lock, 988/911, app locked
- ⚠Patient requests clinical advice → scripted redirect to PCP/Urgent Care/ER
- ⚠Any adverse event or safety concern → Tier 2/3
- ⚠New or escalating acute pain → NP review before resume; in-person eval required
- ⚠Cardiac red-flag zones (chest, left arm/shoulder, upper-left thoracic) + exertional or new onset → Emergency, 911
Escalation Tiers & SLAs
Section 6.4 — four-tier escalation hierarchy.
Tier 1 · Companion
24 hrs
Engagement drop-off, missed check-ins, mild pain increase. Scripted outreach.
Internal CoachFlow Companion (unlicensed, protocol-driven)
Tier 2 · NP
4 hrs
Sustained pain elevation, positive depression screen, patient request for clinical guidance.
Board-certified Nurse Practitioner (FNP / AGNP / PMHNP)
Tier 3 · Medical Director
2 hrs
Adverse events, scope-exceeding clinical questions, medication safety concerns.
Licensed physician (MD or DO), state-licensed in PC operating state
Emergency
Immediate
Suicidal ideation (988), chest/cardiac red-flag (911), stroke symptoms, immediate safety risk.
External — 911 / 988 with simultaneous internal escalation
CPT Codes — RTM Family
What CoachFlow bills. CMS labor type L037D permits MTA-class clinical staff for treatment-management codes.
| Code | Name | CMS Requirement | Billable |
|---|---|---|---|
| 98975 | RTM setup + education | Initial set-up and patient education on equipment use | Once per episode |
| 98985 | Device supply, 2–15 days | Patient transmits data on 2–15 days in 30-day period (MSK) | Per 30-day period |
| 98977 | Device supply, 16–30 days | Patient transmits data on 16–30 days in 30-day period (MSK) | Per 30-day period |
| 98979 | Treatment mgmt, 10 min | 10 min clinical staff time, 1 real-time interaction, 2–15 day supply | Mutually exclusive with 98980 |
| 98980 | Treatment mgmt, 20 min | 20 min clinical staff time, 1 real-time interaction, 16–30 day supply | Mutually exclusive with 98979 |
| 98981 | Treatment mgmt, addtl 20 min | Each additional 20 min beyond 98980 | Add-on code only |
ICD-10 Standing-Order Categories
Section 5 — illustrative, not exhaustive. Each ordering provider configures their own list via standing orders.
Musculoskeletal & Pain
- M15–M19Osteoarthritis (multiple joints / knee / hip / hand)
- M54.xDorsalgia (back pain)
- M79.7Fibromyalgia
- M25.5xPain in joint
- G89.4Chronic pain syndrome
- M48.0xSpinal stenosis
Behavioral Health
- F32.xMajor depressive disorder, single episode
- F33.xMajor depressive disorder, recurrent
- F41.xAnxiety disorders
- F43.2xAdjustment disorders
- F40.xPhobic anxiety disorders
- F42.xObsessive-compulsive disorder
Cognitive & Neurological
- G31.84Mild cognitive impairment
- F03.xUnspecified dementia
- R41.81Age-related cognitive decline
- G47.xSleep disorders
- R45.xSymptoms involving emotional state
Quality of Life & Recovery
- Z73.xProblems related to life management
- Z63.xOther problems related to primary support group
- Z71.xPersons encountering health services for counseling
- Z51.81Encounter for therapeutic monitoring
Eligibility Logic — Section 5
- ELIGIBLE
PEG-3 average ≥ 4 → eligible for RTM enrollment under standing orders. - ALT-SCREEN
PEG-3 ≤ 3 with no qualifying pain → ineligible by pain pathway; route to GAD-7 / alternate validated screens for alternate dx (anxiety, mood, cognitive). - INELIGIBLE
PHQ-2 = 0 AND no qualifying pain (PEG ≥ 4) → ineligible. - SUB-BRANCH
PEG-3 ≥ 7 → branch to duration/severity. Pain >3 mo → chronic pathway; <3 mo → PCP follow-up before enrollment.
Source: CoachFlow_Clinical_Governance_v3c.pdf · Sections 1, 2, 5, 6. Diagnosis selection and medical necessity remain with the ordering clinician under standing orders.