• Medicare began paying in 2015.
• Physicians may now bill for CCM every month when at least 20 minutes of non-face-to-face care is provided by clinical staff.

• Care is provided via phone, email, text, and fax.
• Records and documents each encounter and time spent coordinating care with the client.
• Review medical records and test results self-management education and support.
• Providing referrals and facilitating follow-ups for patients after hospital discharge.
• Coordinates with home health and community-based service providers.
• Documents activities in patient’s medical records.
• Creates comprehensive care plan in EMR.

The patient’s verbal or written agreement to receive CCM services must be obtained before CCM service is provided.  

Patients should be informed of applicable cost sharing that may apply.

Informed that they can stop receiving CCM services at any time.

Acknowledge that only one practitioner (and/or hospital) can provide CCM services for them in a calendar month.

Patient’s consent must be documented in the patient’s medical record.

Why is Chronic Care Management Important?

For patients:

Between doctor visits, taking the right medications at the right times, and following advice from different health care professionals, managing chronic conditions like diabetes or arthritis can be overwhelming.

If you have Medicare, ask your doctor about chronic care management (CCM) services to get connected care, so you can spend less time managing your care and more time doing what you love.

Chronic care management services may include:

• • At least 20 minutes a month of CCM services
  • Personalized assistance from a dedicated health care professional who will work with you to create a care plan
  • Coordination of care between your pharmacy, specialists, testing centers, hospitals, and more
  • 24/7 emergency access to a health care professional
  • Expert assistance with setting and meeting your health goals

• Gain a team of dedicated health care professionals who can help them plan for better health and stay on track for sustaining quality of life.
• Your calls are answered by trusted professionals who have access to their health information and are ready to provide the care they need.
• Community resources are brought to patients as they focus on other important things in life and are not engulfed by taking care of their health.

SCC supports your practice by:

• Unloading patient calls from office support staff.
• Improving care coordination and patient care.
• Supports patient compliance and helps patients feel more connected to their care team.
• Decrease hospital re-admission rates and ER visits.
• Sustain and grow your practice thereby improving patient satisfaction and more revenue for the practice.
• Added extension to your office without dealing with the strain of hiring and training new staff.
• Extra time for your current staff to focus on the in-office patient experience.

• Alzheimer’s and related dementias
• Diabetes
• Hypertension
• Arthritis
• Cardiovascular Diseases
• HIV/AIDS
• Coronary Artery Disease
• Cardiovascular Accident (Stroke)
• Depression
• CHF/COPD
• Cancer
• AFib
• Autism