- Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
- Patient consent (verbal or signed)
- Personalized care plan in a certified EHR and a copy provided to patient
- 24/7 patient access to a member of the care team for urgent needs
- Enhanced nonfacetoface communication between patient and care team
- Management of care transitions
- At least 20 minutes of clinical staff time per calendar month spent on nonface other qualified health care professional
- CCM services directed by physician or CCM services provided by a physician or other qualified health care professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities
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555-555-5555