Comprehensive Chronic Care Management (CCM) Notes

Reporting Month/Year: November 2024 Patient Information Full Name: John Doe Date of Birth (DOB): 01/15/1950 Medical Record (MR) #: 123456789 Type of Residence: Home Chronic Conditions (2 or more required for eligibility) - Hypertension (ICD-10: I10) – The patient has stage 2 hypertension with a blood pressure consistently above 140/90 mmHg. Clinical indicators include elevated systolic and diastolic readings. - Management plan includes Lisinopril 20 mg daily, low-sodium diet, regular blood pressure monitoring, and bi-weekly telehealth check-ins. - Type 2 Diabetes Mellitus (ICD-10: E11.9) – The patient has poorly controlled diabetes with an HbA1c of 8.5%. Clinical indicators include elevated blood glucose levels and neuropathy. - Management plan includes Metformin 500 mg twice daily, dietary modifications, regular blood glucose monitoring, and monthly endocrinologist consultations. Other Medical Conditions - Hyperlipidemia – The patient has elevated cholesterol levels impacting cardiovascular health. - Management strategy includes Atorvastatin 10 mg daily, dietary changes, and quarterly lipid panel tests. - Osteoarthritis – The patient experiences joint pain and stiffness, affecting mobility. - Management strategy includes physical therapy, NSAIDs as needed, and referral to an orthopedic specialist. Other Needs (Social and Access to Care) - Transportation Needs: Relies on community services for medical appointments. - Social Support System: Supported by family and local senior center resources. - Nutritional Needs: Requires low-sodium and low-sugar diet; referred to a dietitian. - Psychosocial and Mental Health Needs: Mild depression managed with counseling and support groups. - Functional Limitations: Requires assistance with ADLs due to joint pain. Physician or Qualified Health Professional (QHP) Responsible for CCM Primary Physician/QHP: Dr. Emily Carter, MD Date Initial Plan of Care Developed: 10/01/2024 Date Plan of Care Provided to Patient/Caregiver: 10/05/2024 Consent Documentation - Verbal or Written Consent Obtained: Yes - Date of Consent: 10/01/2024 - Consent Notes: Patient expressed concerns about medication costs, discussed potential financial assistance. Care Plan Components - Assessment of Patient’s Medical, Functional, and Psychosocial Needs: Comprehensive review of chronic conditions, mobility issues, and mental health status. - Preventive Care Needs Addressed: Annual flu vaccination and diabetic foot exam performed. - Medication Reconciliation and Self-Management Plan: Current medications reviewed, patient instructed on adherence and lifestyle modifications. - Care Coordination and Communication: - Coordination with Dr. Smith, Endocrinologist, for diabetes management. - Referral to Senior Center for social support services. Care Transition Management - Hospital or Facility Discharges in the Past 30 Days: No - Recent Emergency Department Visits: No - Follow-up Actions Required: Continue regular monitoring and scheduled appointments. - Continuity of Care Documents Shared: Yes Chronic Care Management Activities and Time Documentation Date: 11/01/2024 - Activity: Medication review and patient education on lifestyle changes. - Time Start and Stop: 09:00 AM - 09:30 AM - Total Time: 30 minutes - Documentation Reference: EHR Note - Signature: Nurse Jane Smith, RN Date: 11/15/2024 - Activity: Care coordination with endocrinologist and dietitian. - Time Start and Stop: 10:00 AM - 10:45 AM - Total Time: 45 minutes - Documentation Reference: Call Notes - Signature: Nurse Jane Smith, RN Date: 11/29/2024 - Activity: Follow-up on patient’s adherence to care plan and psychosocial support. - Time Start and Stop: 11:00 AM - 11:30 AM - Total Time: 30 minutes - Documentation Reference: EHR Note - Signature: Nurse Jane Smith, RN Total CCM Time for Month: 105 minutes Billing Codes and Documentation - 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time - 99489 – Additional 30 minutes of CCCM (Enter number of units: 1) - 99490 – Standard Chronic Care Management (CCM), at least 20 minutes of clinical staff time - 99439 – Additional 20 minutes of CCM (Up to 2 units) - 99491 – CCM, at least 30 minutes of physician time - 99X21 – Additional 30 minutes of physician time - 99X22 – Principal Care Management (PCM), at least 30 minutes of physician time Supervising Physician or QHP Signature Dr. Emily Carter, MD Date: 11/30/2024