chronic care management program

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

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

More general terms

• case management; chronic care management