Initiating Visit-Initiation during an AWV, IPPE, or face-to-face E/M visit for all patients (Level 4 or 5 visit not required).

Initiating Visit-Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required) for new patients or patients not seen within 1 year

Structured Recording of Patient Information Using Certified EHR Technology– Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.

Structured Recording of Patient Information Using Certified EHR Technology– Structured recording of demographics, problems, medications and medication allergies using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.

24/7 Access to Care-Access to care management services 24/7 (providing the beneficiary with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs regardless of the time of day or day of the week).

24/7 Access to Care-Provide 24/7 access to physicians or other qualified health professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week.

Continuity of Care-Continuity of care with a designated practitioner or member of the care team with whom the beneficiary is able to get successive routine appointments

Continuity of Care-Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.

Comprehensive Care Management– Care management for chronic conditions including systematic assessment of the beneficiary’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications.

Electronic Comprehensive Care Plan-Creation of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues

Electronic Sharing of Care Plan-Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (by fax in extenuating circumstance) as appropriate with other practitioners and providers.

Electronic Sharing of Care Plan-Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary’s care.

Beneficiary Receipt of Care Plan– Provide the beneficiary
with a written or electronic copy of the care plan.

Beneficiary Receipt of Care Plan– A copy of the plan of care must be given to the patient or caregiver.

Documentation of care plan provision to beneficiary-Document provision of the care plan as required to the beneficiary using certified EHR technology

Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Format clinical summaries according to certified EHR technology (content standard).
-Not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (by fax in extenuating circumstance).

Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers.

Home- and Community-Based Care Coordination-Coordination with home and community based clinical service providers.

Documentation of Home- and Community-Based Care Coordination-Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record using certified EHR technology.

Documentation of Home- and Community-Based Care Coordination-Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record.

Enhanced Communication Opportunities-Enhanced opportunities for the beneficiary and any caregiver to
communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods.

Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Document the beneficiary’s written consent and authorization using certified EHR technology

Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month).
-Document in the beneficiary’s medical record that the required information was explained and whether the beneficiary accepted or declined the services.