Chronic Care Management (CCM) Care Plan and Monthly Service Log

Service Period: [Calendar month with start/end dates]

Patient: [Full name], [DOB], [MRN]

Billing Practitioner: [Name], [Credentials], [NPI]

Practice/Location: [Practice name and site/location]

Document Type: CCM Monthly Care Plan & Service Log

CCM Program Status

Eligibility: [Confirmation that patient has ≥2 chronic conditions expected to last at least 12 months and pose significant risk; list specific conditions managed under CCM] (If eligibility cannot be confirmed, state that CCM is not billable for this month and do not complete billing-related sections.)

Initiating Visit Reference: [Date], [Visit type: comprehensive E/M / AWV / transitional care], [Rendering clinician name and credentials] (This is a stable anchor reference; update only if an error is identified.)

Consent Status: [Active / Not on file / Expired] — [Date obtained], [Method: verbal / written], [Obtained by: name/role]

• CCM service availability and scope explained
• Potential cost-sharing/coinsurance discussed
• Only one practitioner may bill CCM per calendar month
• Right to discontinue at the end of any month

(If consent remains active from a prior month, reference the original consent date. If eligibility or consent cannot be confirmed, CCM is not billable for the month.)

Care Team & Access

Care Team:

• [Billing practitioner: name, credentials, role, contact method]
• [Care manager/clinical staff: name, credentials, role, contact method]
• [External clinicians: name, specialty, role in care, contact method]
• [Caregiver: name, relationship, contact method, communication preferences / No caregiver identified / Patient self-manages]

24/7 Access: [After-hours access method: phone line / on-call service / nurse triage], [Routine contact method], [Portal/secure messaging availability] (Update only when access methods change.)

Comprehensive Care Plan

Care Plan Status: Start date: [Date]. Last review: [Date]. Last revision: [Date]. Care plan copy provided to patient/caregiver: [Yes / No / Unknown] — [Date and method if provided]. (If not yet provided, note plan to provide a copy.)

Patient Priorities & Context: [Patient-stated priorities and goals], [Health literacy/language considerations], [Functional/cognitive factors affecting self-management], [Key barriers or facilitators: transportation, cost, housing, caregiver support] (If not yet assessed, note plan to assess.)

Problem List (Order by clinical priority; include risk flags such as recent hospitalization, polypharmacy, falls risk, or frequent ED use where relevant.)

Problem/Diagnosis (ICD-10 if available)	Status	Key Monitoring Parameters
[Problem/Diagnosis]	[stable / improving / worsening / new]	[Symptoms, vitals, labs, devices, risk flags]

Goals & Interventions by Problem (For each active problem managed under CCM; keep focused on actionable items.)

[Problem name]:

• Goal: [Patient-centered goal with measurable target and timeframe] (If goals cannot be defined this month, state reason and plan to establish.)
• Interventions: [Intervention and responsible party: patient / caregiver / care manager / practitioner]
• Monitoring: [Frequency and escalation triggers]

Medication Management: Medication reconciliation performed this month: [Yes / No] — [Date if performed]. High-risk medications requiring monitoring: [List or N/A]. Adherence issues: [Yes / No] — [Details and mitigation plan if applicable]. (Reference that full medication list is maintained in EHR; document only relevant changes or concerns here.)

Psychosocial & Community Needs: [Social determinants affecting care: food insecurity, transportation, housing, financial strain], [Community/home services involved: home health, PT/OT, meal programs, case management] (If not assessed, note plan to assess.)

Escalation Plan: Red-flag symptoms: [Disease-specific warning signs]. Contact instructions: [Care team contact for urgent issues], [After-hours/on-call method], [When to call 911/go to ED]. [Disease-specific action plan references if applicable]

Monthly Summary

Interval Events: [Hospitalizations, ED visits, or urgent care since last month with date, facility, reason], [New diagnoses], [Significant symptom changes], [Key results reviewed: labs, imaging, specialist recommendations] (If none, state: No interval hospitalizations or ED visits this month.)

Progress Toward Goals:

• [Problem]: [achieved / improving / unchanged / worsening / not assessed] — [Evidence source: patient report / device data / labs / clinical observation]

Care Plan Updates:

• [Change made] — [Rationale] — [Patient/caregiver and relevant clinicians notified: Yes / No]. Updated care plan copy provided: [Yes / No].

(If no changes this month, state: Care plan reviewed; no changes required this month.)

Care Coordination: [Post-discharge follow-up], [Referrals made and outcomes], [Coordination with home health/community services], [Information exchanged with external clinicians] (If no coordination activities this month, state explicitly.)

Monthly Service Log

(Complete only if eligibility and consent are confirmed for the current month.)

Time Summary: Total clinical staff minutes: [Minutes]. Total billing practitioner minutes: [Minutes or N/A]. Total CCM minutes counted toward billing: [Minutes]. CCM pathway: [Clinical staff under general supervision / Practitioner personally performed time]

Activity Log (Entries should be specific and outcome-oriented.)

Date	Staff	Mode	Recipient	Activity Description	Minutes	Problem Linked	Result/Next Step
[MM/DD/YYYY]	[Name, credentials]	[phone / portal / chart review / coordination call / fax / other]	[patient / caregiver / specialist / pharmacy / home health / other]	[Specific activity with purpose]	[#]	[Problem/diagnosis]	[Outcome and next step]

Unsuccessful Contact Attempts: [Date, method, result (no answer / voicemail left), next attempt plan] (Do not count time unless permissible by organizational policy.)

Attestations

• Patient meets CCM eligibility criteria this month: [Yes / No / Unable to confirm]
• Informed consent is on file and active: [Yes — Date / No / Unable to confirm]
• Comprehensive care plan exists, was reviewed/revised as needed, and is available within and outside the practice: [Yes / No]
• Patient/caregiver has been provided a care plan copy (or plan to provide documented): [Yes / No / Planned]
• 24/7 access method and continuity contact have been communicated to patient: [Yes / No]
• Time documented is accurate, contemporaneous, and not counted toward any other billed time-based service: [Yes / No]
• Only one practitioner is billing CCM for this patient this month: [Yes / No / Unknown]
• Concurrency with other time-based services reviewed with no prohibited overlaps: [Yes / No]

(If any attestation cannot be confirmed, document the specific issue and route to compliance review before billing: [Issue identified and resolution plan])

Signatures

Clinical Staff: [Name, credentials, date/time]

Billing Practitioner: [Name, credentials, date/time] (for review/oversight)

(Note remains in draft status until authenticated per organizational policy. Do not fabricate content; if required information is unavailable, indicate what is missing and the plan to obtain it. When no interval events or coordination activities occurred, state this explicitly rather than leaving sections empty.)