Chronic Care Management at Colorado Clinic

I think this service is great and you do an amazing job. Every time I talk you guys you have helped me in every way possible and have answered all of my questions. I thank you so much.
Pamela

Here are the links to the forms for participation:

 

What is Chronic Care Management?

Chronic care management is a major component of primary care that promotes better health and reduces overall healthcare costs. Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

What does chronic care management cover?

Chronic care management covers phone calls, emails, management of referrals to providers, ongoing review of patient status, and management of prescriptions. The scope of services includes:

  • Access to care management 24 hours a day and 7 days a week.
  • Care management for chronic conditions, such as assessment of psychosocial, medical, and functional needs, medication reconciliation, and approaches to ensure preventive services are rendered.
  • Creation of a patient-centered care plan document.
  • Management of care transitions that incudes referrals, follow-up after emergency department visit, hospital, or other care facility.
  • Coordination with community-based and home-based clinical service providers.
  • Enhanced opportunities for patients and caregivers.
  • Electronic capture and sharing of care plan data/information.

What conditions are treated under chronic care management?

Chronic care management is used for many chronic conditions, which include but are not limited to:

  • Degenerative disc disease
  • Rheumatoid arthritis
  • Scleroderma
  • Inflammatory arthritis
  • Multiple sclerosis
  • Parkinson’s disease
  • Stroke
  • Cerebral palsy
  • Complex regional pain syndrome
  • Congestive heart failure
  • Chronic pulmonary disease
  • Autoimmune disease
  • Asthma

Who participates with CMS’s chronic care management?

Practitioner eligibility includes physician, nurse practitioners, certified nurse midwives, physician assistants, and certified nurse specialists. CCM may be billed by primary care practitioner, but certain specialty physicians and practitioners. However, CCM is not available for clinical psychologists, dentists, or podiatrists.

What are the patient eligibility requirements for chronic care management?

Eligibility includes:

  • Patients with two or more chronic conditions, which are expected to last 12 months or until the death of the patient.
  • Conditions that place the patient at significant risk of death.
  • Patients who have functional decline, decompensation, or acute exacerbation of a chronic illness.

What can I expect with a chronic care management service?

CMS recognize care management as an important aspect of healthcare that contributes to reduced spending. Chronic care management requires that the clinical staff spends at least 20 minutes per patient each month to establish, implement, revise, and monitor a care plan.

What is in the chronic care management care plan?

The care plan is based on the patient’s mental, physical, psychosocial, functional, and environmental needs. The details of this plan are consistent with the patient’s choices and values. The patient-centered care plan includes a plan for preventive services, oversight of medication (compliance and reconciliation), and periodic assessment of patient’s needs. In addition, the care plan has a problem list, expected outcome, measurable treatment goals, symptoms management, planned interventions, and prognosis

What are the results and benefits of chronic care management?

The results/benefits of chronic care management include:

  • Patient response and connectivity – Patients enjoy chronic care management, and response rate has been good.
  • Low effort and resource requirements – Patients under chronic care management enjoy a dedicated team of care givers who monitor medicines, help with referrals, and work with healthcare facilities to improve overall well-being.

Resources

  • Moore K (2015). Chronic Care Management and Other New CPT Codes. Fam Pract Manag, 22(1), 7-12.
  • Nuwer MR (2015). Chronic care management coding for neurologists. Neurol Clin Pract, 5(5), 430-438.

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