Chronic Care Management (CCM) is a set of coordinated services provided outside of the regular office visit. These services are provided to Medicare patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, that place the patient at significant risk of death or functional decline. The first chronic care management code was added in 2015 and an additional three codes were added in 2017 to allow for additional billing for complex patients. These services include phone and electronic communication, accessibility, and the establishment of electronic care plans. Patients in a long-term or skilled nursing facility are not eligible.
Codes for this service are included in the Medicare Physician Fee Schedule. Physicians and the following health care professionals can bill for chronic care management services: Physician Assistants, Clinical Nurse Specialists, Nurse Practitioners, and Certified Nurse-Midwives.
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