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Chronic Care Management

Chronic care management service elements

Part 3: Chronic care management service elements

For healthcare organizations to receive approved monthly chronic care management (CCM) reimbursements, they must provide extensive services, typically outside of face-to-face patient visits.

Service requirements include:

Structured recording of patient health information

Providers must record the patient's demographics, problems, medications, and medication allergies using EHR technology currently certified under the Medicare and Medicaid EHR Incentive Programs.

Comprehensive care plan

Providers must electronically provide a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, with particular focus on the chronic conditions being managed, and an inventory of resources. They must provide a copy of the care plan to the patient and/or caregiver, ensure the electronic care plan is available and shared within and outside of the billing practice to those involved in the patient's care, and ensure care planning tools and resources are publicly available from a number of organizations.

A comprehensive care plan for all health issues typically includes, but is not limited to, these elements:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identification of the individuals responsible for each intervention
  • Medication management
  • Community and social services ordered
  • Description of external agency and specialist direction and coordination
  • Schedule of periodic care plan review and, when applicable, revision

Access to care and care continuity

Providers must provide patients with 24x7 access to physicians or other qualified healthcare professionals or clinical staff. A designated care team member must be available to the patient for routine appointments to ensure continuity of care. They must also enable the patient and their caregiver(s) to be able to communicate with the practitioner by phone, secure messaging, secure internet, or other asynchronous non–face-to-face consultation methods (e.g., email or secure electronic patient portal).

Comprehensive care management

Comprehensive care management includes:

  • Assessing patients’ medical, functional, and psychosocial needs
  • Ensuring patients receive all recommended preventive care services in a timely manner through system-based approaches
  • Reconciling medication, while reviewing adherence and potential interactions
  • Overseeing patients’ self-management of medications
  • Coordinating care with home and community-based clinical service providers

Transitional care management

Transitional care management includes:

  • Managing transitions between and among healthcare providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge
  • Creating, exchanging, and transmitting continuity of care document(s) with other practitioners and providers