How Do I Get Started With CCM Services?

Scope of Service Elements and Requirements

CCM services are non-face-to-face activities performed by you or your clinical staff to manage and coordinate the care of your patients. To initiate the services, Medicare requires that you first obtain a patient’s informed and written consent* during a face-to-face visit, such as during an initial preventive physician exam, annual wellness visit, or comprehensive evaluation and management visit billed separately.

Among other elements and requirements, practices must be able to:  

  • Provide care management services, manage care transitions, and coordinate care;
  • Use structured data recording via certified electronic health record (EHR) technology;
  • Create and maintain a comprehensive, patient-centered care plan that is electronically available at all times to you or designated member of the care team involved in care management services;
  • Ensure 24/7 access to care management services that gives patients and caregivers a way to make timely contact with you or designated member of the care team who has access to the patient's electronic care plan to address urgent needs related to their chronic conditions;
  • Ensure a patient’s continuity of care with you or designated member of the care team through successive routine appointments; and
  • Provide enhanced opportunities for patient and caregiver communication with you or designated member of the care team through telephone or other non-face-to-face method in compliance with HIPAA. 
You must comply with Medicare’s scope of service elements and billing requirements to bill for the services. Contact your EHR vendor to inquire whether your system is able to meet the requirements or if your vendor can make the needed changes to support your practice in providing these services as outlined by Medicare.

*See sample consent forms on the resources and tools webpage.


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Last Updated On

August 19, 2021

Originally Published On

April 10, 2016

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