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CCM can help you deliver coordinated care to your patients that will improve their health, increase satisfaction with their care, and make care more person-centered.
Assess the patient. The first step to writing a care plan is performing a patient assessment. This includes reviewing your patients medical history, diagnosis, lab values, and medications. This step is critical to creating an effective and accurate care plan for either short term or long term care.
Every care plan should include: Personal details. A discussion around health and well being goals and aspirations. A discussion about information needs. A discussion about self care and support for self care. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
6 Tips for Documentation Success An explanation of the CCM and its availability. An explanation that the patient can revoke the service. A portion explaining that only one provider can bill for this service for each patient. An explanation on what information may be shared between physicians.
Under CPT 99490, clinical staff supervised by a physician or other qualified healthcare professional can perform CCM for billing purposes. CPT 99491 compensates physicians or other qualified healthcare professionals for time spent on CCM-related care and requires them to provide such care personally.
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Information that should be included within a comprehensive care plan can be grouped into eight components including: Clinical assessment and diagnosis. Goals of care. Risk screening and assessment. Planned interventions. Activities of daily living. Monitoring plans. People involved in care. Discharge planning.
What Are the Components of a Care Plan? Step 1: Assessment. The first step of writing a care plan requires critical thinking skills and data collection. Step 2: Diagnosis. Step 3: Outcomes and Planning. Step 4: Implementation. Step 5: Evaluation.
When building a care plan, the CCM team might add: A list of the medical conditions being addressed. The patients prognosis and expected outcomes. Notes on symptoms. Details about medication management. Relevant notes from other practices and specialists. Quantifiable care goals.

ccm care plan template