CPT copyright 2016 American Medical Association. All rights reserved.
Figure B-5. Chronic Care Management Worksheet
Reporting month/year Patient
DOB MR# Type of residencea
Chronic condition(s):
Other medical conditions:
Other needs (social, access to care):
Physician/QHP Date initial plan of care developed
Date plan of care provided to patient/caregiver
Clinical Staff Documentation: In the table below, include date, activity description, time spent, and location
of any associated documentation (eg, plan of care, call notes). Activities may include
EECommunication (with patient, family members, guardian/caregiver, surrogate decision makers, or other
professionals) about aspects of care
EECommunication with home health agencies and other community services used by the patient
EECollection of health outcomes data and registry documentation
EEPatient or family/caregiver education to support self-management, independent living, and activities of
daily living
EEAssessment of and support for treatment regimen adherence and medication management
EEIdentification of available community and health resources
EEFacilitating access to care and services needed by the patient/family
EEManagement of care transitions not reported as part of transitional care management (99495, 99496)
EEOngoing review of patient status, including review of laboratory and other studies not reported as part of
an E/M service
EEDevelopment and maintenance of a comprehensive care plan
Activity (include reference to other
documentation when indicated)
Time (start
and stop)
Clinical Staff
Signature (legible/
Total Time min
____ 99487 first hour of clinical staff time with care plan establishment/substantial revision, per calendar month
____ 99489 each additional 30 minutes of clinical staff time per calendar month (Enter number of units.)
____ 99490 at least 20 minutes of clinical staff time per calendar month
Supervising physician/QHP signature__________________________________________________________________
Abbreviations: DOB, date of birth; E/M, evaluation and management; MR, medical record; QHP, qualified health care professional.
Specify if patient lives in a private residence, group home, or other type of domiciliary. Do not report chronic care management services for patients residing
in a facility that provides more than minimal medical care (eg, nursing facility).
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