The plan will help support the patient’s disease control and health management goals, including physical, mental, cognitive, psychosocial, functional and environmental factors. Patients and caregivers may also receive a list of suggested resources and, if available, community services, and may be encouraged to keep track of referrals, community support and educational information.
A patient with a qualifying condition that is expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
A patient with a qualifying condition that is expected to last between 3 months and 1 year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline.
Prior to the start of CCM/PCM services, a comprehensive initiating visit is required for new patients or patients not seen within one year. Initiating visits can include (a) Initial Preventive Physical Examination (IPPE), (b) Annual Wellness Visit (AWV), or (c) Evaluation and Management service (E/M). This initiating visit is not part of CCM/PCM services and is billed separately. While CCM/PCM services do not have to be discussed during the initiating visit, this visit must occur during the year (12 months) prior to the start of CCM/PCM.
Obtained during or after initiating visit and before provision of care coordination services by RHC or FQHC practitioner or clinical staff.Written or verbal, documented in the medical record.
Two or more chronic conditions for CCM, or a single high-risk condition for PCM.
Conditions expected to last at least 12 months or until death.
Conditions that put the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Two or more chronic conditions for CCM, or a single high-risk condition for PCM.
Conditions expected to last at least 12 months or until death.
Conditions that put the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
