Complex chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of de
CPT4 code
Name of the Procedure:
Complex Chronic Care Management Services (CCCM), also known as Comprehensive Care Management, Chronic Care Coordination.
Summary
Complex Chronic Care Management services involve coordinating medical care for patients with two or more chronic conditions, lasting at least 12 months or until the patient's death. These services include regular follow-ups, medication management, and personalized health plans designed to reduce hospitalizations and improve patients' quality of life.
Purpose
Medical Condition: Multiple chronic conditions such as diabetes, heart disease, COPD, etc. Goals: To improve health outcomes, enhance the quality of life, reduce hospital admissions, and manage symptoms and treatment plans of chronic diseases more effectively.
Indications
Symptoms/Conditions: Multiple chronic conditions like hypertension, diabetes, or COPD. Patient Criteria: Patients with significant risk of death, increased hospitalization probability, or decline in health status due to chronic conditions.
Preparation
Pre-procedure Instructions: No specific fasting or medication adjustments needed. Diagnostic Tests: Routine lab tests, current medications review, and comprehensive health assessment might be necessary beforehand.
Procedure Description
- Initial Patient Assessment: Comprehensive evaluation of the patient's medical history, current conditions, and treatment plans.
- Care Plan Development: Creating a personalized plan that includes medication management, lifestyle changes, and regular monitoring.
- Coordination With Specialists: Ongoing communication with various healthcare providers to ensure cohesive care.
- Regular Follow-Ups: Scheduled appointments, either in-person or virtual, for continuous monitoring and adjustments.
- Tools/Technology: Electronic health records (EHR), telehealth services, patient monitoring devices.
- Sedation/Anesthesia: Not applicable.
Duration
Typical Time: Ongoing service with regular check-ins that can range from monthly to bi-monthly, depending on the patient's needs.
Setting
Location: Outpatient clinic, physician's office, or via telehealth platforms.
Personnel
Healthcare Team: Primary care physicians, nurses, case managers, specialists (e.g., cardiologists, endocrinologists).
Risks and Complications
Common Risks: Minimal risk involved. Possible Complications: Miscommunication or lack of coordination between multiple healthcare providers could lead to treatment inconsistencies.
Benefits
Expected Benefits: Improved management and control of chronic conditions, reduced risk of hospitalization, enhanced overall health and quality of life. Timeline: Benefits can be seen shortly after consistent management begins, typically within a few months.
Recovery
Post-Procedure Care: Ongoing assessment and adjustments based on patient needs. Recovery Time: Continuous process with no specific recovery time. Follow-up Appointments: Regular, depending on the care plan.
Alternatives
Other Options: Standard primary care without specialized management, disease-specific programs, self-management. Pros and Cons: Alternatives may not provide as comprehensive or coordinated care, potentially leading to more frequent hospitalizations and poorer health outcomes.
Patient Experience
During Procedure: Patients will experience structured and consistent follow-up, a supportive healthcare team, and continuous communication. After Procedure: Improved health outcomes may lead to a better quality of life. Pain management is generally not a concern as this service is more about coordination and management rather than physical procedures.