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We do our best to be accommodating to all individuals with disabilities, but if you need additional assistance, please call our office, or send us an email so that we can provide support.
Chronic Care Management (CCM) is non-face-to-face services provided to 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.
In addition to office visits and other face-to face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM. The designated CCM clinician must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient as well as maintain an inventory of resources and supports that the patient needs. Only one clinician can bill for any particular patient therefore it may be necessary to coordinate with the sub-specialists who may be providing a significant amount of care and treatment to one or more of the patient’s conditions. It will be important that the patients understand only one of their likely multiple physicians will be able to bill for CCM services. These codes are generally intended for use by the clinician who is providing the majority of the care coordination services, which most often would be the primary care internist.
For more information please see the following link:
Note – Even if you don’t have 2 or more chronic conditions but wish to participate in a tailored program unique to your needs, please contact us to discuss.
