American College of Physicians (ACP) 2015 Medicare Chronic Care Management Toolkit

Chronic Care Management (CCM) has been defined by Medicare as the non-face-to-face services provided to beneficiaries who have multiple (two or more), significant chronic conditions. Recently, the ACP has created a toolkit for implementing a program.

In addition to office visits and other face-to-face encounters (billed separately), CCM services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM.

CMS has provided a CCM Services Fact Sheet with a variety of resources, FAQs, and other information about chronic care management, which we reported last year.  In the toolkit, several steps have been identified to implement a reimbursable program including:

  1. Identify the patients

  2. Designate a primary clinician

  3. Add patient to the Chronic Care Management

  4. Inform the Patient

  5. Create and Document a Comprehensive Care Plan

  6. Provide the patient with the written or electronic copy of the comprehensive care plan

  7. Document the Time Spent

  8. Termination from program

To obtain a copy of the ACP CCM Toolkit packed with interesting plans and procedures, click here >>