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Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. In addition to office visits and other face-to-face encounters, these 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. The designated CCM clinician (MD, PA, NP) must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psycho-social, functional and environmental needs of the patient as well as maintain an inventory of resources and supports that the patient needs. Thus, the practice must use a certified EHR to bill CCM codes.  Only one clinician can bill for any particular patient therefore it may be necessary to coordinate with the sub-specialists who may be providing a significant amount of care and treatment to one or more of the patient’s conditions. It will be important that the patients understand only one of their likely multiple physicians will be able to bill for CCM services. These codes are generally intended for use by the clinician who is providing the majority of the care coordination services, which most often would be the primary care internist. However, certain specialists may be able to provide the services needed to qualify to bill the CCM codes, but never in the same month as the primary care physician.

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