In addition to time, the provider/clinical staff must document the following required elements, per CPT:
- One complex chronic condition expected to last at least three months, that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death
- The condition requires development, monitoring, or revision of diseasespecific care plan
- The condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities
- Ongoing communication and care coordination between relevant practitioners furnishing care