Generic Chronic Care Management (CCM) Plan Notes

Reporting Month/Year: November 2024 Patient Information: Name: John Doe Date of Birth (DOB): 15 March 1950 Medical Record (MR) #: 123456789 Type of Residence: Assisted Living Chronic Conditions: - Hypertension (ICD-10: I10), diagnosed 2010. Managed with Lisinopril 10mg daily, low-sodium diet, and regular blood pressure monitoring. - Type 2 Diabetes Mellitus (ICD-10: E11.9), diagnosed 2015. Managed with Metformin 500mg twice daily, dietary adjustments, and regular blood glucose monitoring. Other Medical Conditions: - Hyperlipidemia (ICD-10: E78.5). Managed with Atorvastatin 20mg daily and dietary modifications. Other Needs (Social & Access to Care): - Transportation Issues: Relies on community transport services for medical appointments. - Social Support: Daughter visits twice a week and assists with medication management. - Nutritional Concerns: Difficulty adhering to diabetic diet; receives meal planning assistance from a dietitian. - Cognitive Concerns: Mild cognitive impairment affecting medication adherence; uses a pill organizer and receives oversight from caregivers. Physician/QHP Responsible for Care Management: Primary Physician: Dr. Emily Carter, MD Date Initial Plan of Care Developed: 1 November 2024 Date Plan of Care Provided to Patient/Caregiver: 1 November 2024 Time Documentation for Chronic Care Management Activities: 1. 5 November 2024 – Telehealth consultation - Time (Start-Stop): 10:00 - 10:30 - Total Time: 30 minutes - Documentation Reference: Telehealth note - Signature: Jane Smith, RN 2. 12 November 2024 – Medication review - Time (Start-Stop): 14:00 - 14:20 - Total Time: 20 minutes - Documentation Reference: EHR entry - Signature: Jane Smith, RN 3. 20 November 2024 – Care coordination with dietitian - Time (Start-Stop): 09:00 - 09:15 - Total Time: 15 minutes - Documentation Reference: Call notes - Signature: Jane Smith, RN Total Time: 65 minutes Billing Codes: - 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time with moderate or high complexity MDM, per calendar month - 99489 – Each additional 30 minutes of clinical staff time per calendar month (1 unit) - 99490 – Chronic Care Management (CCM), at least 20 minutes of clinical staff time per calendar month Supervising Physician/QHP Signature: Dr. Emily Carter, MD Date: 1 November 2024