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The Centers for Medicare & Medicaid Services (CMS) state that a patient with a chronic condition has two chronic continuous or episodic health conditions that are expected to last at least 12 months. The CMS recognizes chronic care management (CCM) as a critical component of primary care that contributes to better health and care for individuals.

In 2015, Medicare began paying separately under the Medicare Physician Fee Schedule (PFS) for CCM services furnished to Medicare patients with multiple chronic conditions. With the shift to value-based care, CMS has approved monthly CCM reimbursements for providers to improve the health outcomes of patients and decrease unnecessary spending.

CCM services – requirements and management

These eight components define CCM services:

  1. 24x7 access to care management services
  2. Continuity of care
  3. Care management for chronic conditions
  4. Creation of a patient-centric care plan to ensure care is provided congruently with patient choices and values
    A plan of care should include:
    1. Problem list
    2. Expected outcome and prognosis
    3. Measurable treatment goals
    4. Symptom management
    5. Planned interventions
    6. Medication management
    7. Community and social services ordered
    8. Description of external service coordination
    9. Individuals responsible for each intervention
    10. Requirements for periodic care plan review and revisions (if applicable)
  5. Management of care transitions between and among healthcare providers and settings, including
    1. Referrals to other clinicians
    2. Follow-up after a patient visit to an emergency room
    3. Follow-up after discharges from hospitals, skilled nursing facilities, or other healthcare facilities
  6. Coordination with home and community-based clinical service providers
  7. Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the beneficiary's care
  8. Electronic capture and sharing of care plan information

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