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
