Chronic Care Management, The Ultimate Scope of Services and Billing Requirements
From CMS Document: ICN909188 May 2015
Care Plan
Develop, Deliver and Regularly Update Comprehensive Plan of Care Based On A Physical, Mental Cognitive, Functional And Psychosocial Assessment. Provide The Beneficiary With A Copy Of Care Plan
Communication Methods
The Provider Must Also Offer Cell/Smart Phone /Texting And Email Communications Options In Addition To Regular Phone Contact In Order To Bill For These Services.
Time Requirement
Provide A Minimum Of 20 Minutes Per Month Of Non-face To Face Care With Each Patient.
Baseline Evaluation of Patient
Establish Comprehensive Chronic Illness Baseline Evaluation From Which All Future Treatment and Care Management Will Evolve. Including A Full List Of Medications and Medication Allergies In The EHR.
Medication Adherence
Provide Medication Reconciliation, Review of Adherence,
And Potential Interactions And Oversight of Beneficiary Self-Management of Medications.
Care Plan Access
24/7/365 Patient Care Plan With Access Available To A Fully Integrated Team Of Patient’s Providers.
Transitional Care
Management of Care Transitions To and From Hospitals, SNF’s Including Referrals To Other Clinicians.
Beneficiary Consent
Inform The Beneficiary Of The Availability Of CCM Services And Obtain His Or Her Written Agreement. Inform The Patient Only One Practitioner Can Furnish These Services In A Calendar Month.
Provide Care Plan Copy
Provide The Beneficiary With A Written Or Electronic Copy Of The Care Plan And Document Its Provision In The Electronic Medical Record.
From CMS Document: ICN909188 May 2015
Care Plan
Develop, Deliver and Regularly Update Comprehensive Plan of Care Based On A Physical, Mental Cognitive, Functional And Psychosocial Assessment. Provide The Beneficiary With A Copy Of Care Plan
Communication Methods
The Provider Must Also Offer Cell/Smart Phone /Texting And Email Communications Options In Addition To Regular Phone Contact In Order To Bill For These Services.
Time Requirement
Provide A Minimum Of 20 Minutes Per Month Of Non-face To Face Care With Each Patient.
Baseline Evaluation of Patient
Establish Comprehensive Chronic Illness Baseline Evaluation From Which All Future Treatment and Care Management Will Evolve. Including A Full List Of Medications and Medication Allergies In The EHR.
Medication Adherence
Provide Medication Reconciliation, Review of Adherence,
And Potential Interactions And Oversight of Beneficiary Self-Management of Medications.
Care Plan Access
24/7/365 Patient Care Plan With Access Available To A Fully Integrated Team Of Patient’s Providers.
Transitional Care
Management of Care Transitions To and From Hospitals, SNF’s Including Referrals To Other Clinicians.
Beneficiary Consent
Inform The Beneficiary Of The Availability Of CCM Services And Obtain His Or Her Written Agreement. Inform The Patient Only One Practitioner Can Furnish These Services In A Calendar Month.
Provide Care Plan Copy
Provide The Beneficiary With A Written Or Electronic Copy Of The Care Plan And Document Its Provision In The Electronic Medical Record.