Chronic Care Management – Eligibility

Patients who have been diagnosed with at least two chronic conditions expected to last at least 12 months.

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Patient Segment Eligibility Description Data Source
Patients diagnosed with 2+ chronic conditions Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline are eligible for the CCM service. Claims/Chronic Condition Warehouse (CCW)

  • Use CCW chronic condition algorithms against ICD and HCPCS codes in claims to identify patients with 2 or more chronic conditions

Chronic Care Management – Implementation

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Time Frame Action
Trigger event Beneficiary diagnosed with multiple chronic conditions expected to last at least 12 months
Within 30 days of trigger event (flexible) Practitioner must inform eligible beneficiary of the availability of and obtain consent for the CCM service before furnishing or billing the service:

  • Inform the patient of the availability of the CCM service and obtain written agreement to have the services provided, including authorization for the electronic communication of medical information with other treating practitioners and providers.
  • Explain and offer the CCM service to the patient. In the patient’s medical record, document this discussion and note the patient’s decision to accept or decline the service.
  • Explain how to revoke the service.
  • Inform the patient that only one practitioner can furnish and be paid for the service during a calendar month.
Once every calendar month, after obtaining beneficiary’s consent Furnish the CCM service:

  • Record/update the patient’s demographics, problems, medications, and medication allergies and create structured clinical summary records using certified EHR technology.
  • Create/update a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources. Provide the patient with a written or electronic copy of the care plan and document its provision in the medical record.
  • Ensure 24-hour-a-day, 7-day-a-week access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.
  • Provide care management services such as: systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.
  • Manage care transitions between and among health care providers and settings, including referrals to other providers
  • Coordinate care with home and community based clinical service providers.

Chronic Care Management – Compliance

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Intervention Intervention Description Data Source
Furnish CCM Service The CCM service includes structured recording of patient health information, an electronic care plan addressing all health issues, access to care management services, managing care transitions, and coordinating and sharing patient information with practitioners and providers outside the practice.

See detailed information on these services on the previous slide for Care Model: Chronic Care Management – Implementation.


Procedure HCPCS codes to identify CCM billing*

*CCM cannot be billed during the same service period as Transitional Care Management (TCM)