Chronic Care Management

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What is CCM?

Chronic Care Management (CCM) services by a physician or non-physician practitioner (Physician Assistant [PA], Nurse Practitioner [NP], Clinical Nurse Specialist [CNS], Certified Nurse-Midwife [CNM]) and their clinical staff, per calendar month, for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Only 1 practitioner can bill CCM per service period (month).


CPT Codes

By using the CCM codes below, your practice can be separately reimbursed for important care management services that it provides to fee-for service Medicare patients with two or more chronic conditions that are expected to last at least 12 months and place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.


The included services are:

Cerified EHR

Use of a meaningful use 2014 Certified Electronic Health Record (EHR).

Continuity of Care

Continuity of Care with Designated Care Team Member

Plan Management

Comprehensive Care Management and Care Planning

Transitional Care Management

Ability to transfer medical data as C-CDA's which is a lot more than just a PDF

Care Corordination

Coordination with Home- and Community-Based Clinical Service Providers

Accessibility

24/7 Access to Address Urgent Needs

Enhanced Communication

Email, Web portal and mobile communication to update patient charts and status)

Consent and Campaign Management

Easy to identify patient and get consent signed.Campaign tools help the practice manage consents.

Dashboard

Customizable dashboard to analyze CCM performance