chronic care management program
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Indications
- >= chronic conditions expected to last >= 12 months or until death
- services that must be provided
- certified electronic medical record
- continuity of care with a designated care team member
- comprehensive care management & care planning
- transitional care management
- interaction & coordination with outside resources & practitioners & providers
- 24/7 access to address urgent needs
- enhanced communication (email)
- implementation may increase revenue for the work being done[1]
Notes
- only 1 practioner can bill per month
- does NOT cover home visits
- Medicare part B will pay physician for home services on a fee for service basis for visits to homebound patients[1]