Appendixes CPT copyright 2018 American Medical Association. All rights reserved. APPENDIX III: CHRONIC CARE MANAGEMENT WORKSHEET ||||||||||| 555 III. Chronic Care Management Worksheet 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 following table, include date, activity description, time spent, and loca- tion 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 Date Activity (include reference to other documentation when indicated) Time (start and stop) Total Time Clinical Staff ­ Signature (legible/ credentials) 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 _________________________________________________________________ Date________________________________________________________________________________________________ Abbreviations: DOB, date of birth E/M, evaluation and management MR, medical record QHP, qualified health care professional. a 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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