Complex Chronic Care Management Monthly Note

Patient: [Name, DOB, MRN]

Service Period: [Month/Year, e.g., January 2026]

Billing Practitioner: [Name, credentials, NPI]

Care Team Contributors: [Names and roles of clinical staff involved]

Place of Service: [POS code for claim]

Note Status: [Complete / Incomplete] (Mark "Incomplete" if Service Period, Billing Practitioner, or Consent are missing. Do not proceed to billing if incomplete.)

Eligibility and Consent Verification

• Qualifying Conditions: [List two or more chronic conditions being managed] (Attest each is expected to last 12+ months or until death.)
• Risk Statement: [Brief statement that conditions place patient at significant risk of death, acute exacerbation, or functional decline, with 1–2 specific clinical factors]
• Consent: [Consent obtained / Prior consent on file / Consent not on file—obtain prior to billing] (If obtained or on file, include date and confirm patient was informed of cost-sharing, single billing practitioner per month, and right to discontinue.)
• Initiating Visit: [Date and type of initiating E/M, AWV, or IPPE]

Complex CCM Justification

Complexity Summary: [2–4 sentence narrative of what drove complex CCM work this month—unstable conditions, diagnostic uncertainty, high-risk medication management, multi-specialty coordination, or psychosocial barriers requiring iterative care plan updates]

Billing Practitioner MDM: [Description of moderate or high complexity medical decision-making performed this period] (Specify decisions made, pertinent data reviewed, and why the overall risk rises to moderate/high complexity. If moderate/high complexity MDM did not occur, do not bill complex CCM.)

Care Plan and Coordination Summary

Care Plan Status: [Comprehensive care plan established / revised / reviewed-monitored this month] (State trigger for any changes and reference care plan location in EHR.)

Key Changes This Month: [Summary of material updates—problems added/resolved, goals modified, interventions changed, new referrals, monitoring adjustments] (If no material changes: "Care plan monitored; no material revisions indicated.")

Coordination Activities: [Summary of care management work performed—patient/caregiver communication, medication management, specialist coordination, transition follow-up, community resource linkage as applicable] (Connect each activity to the care plan.)

Care Plan Access: [Confirm electronic care plan is accessible within and outside the practice] (Note if/how shared with patient or caregiver this month.)

Time Accounting and Billing Attestation

Total CCM Time: [X] minutes for the calendar month

Time Breakdown: [Clinical staff minutes] ; [Billing practitioner minutes if applicable]

Threshold: [Complex CCM base threshold met / Complex CCM base + add-on threshold met]

Attestations:

• Time represents qualifying CCM activities and is not counted toward any other billed service.
• 24/7 access to the care team and continuity processes are in place.
• This practice is the sole CCM billing entity for this patient this month.
• If other time-based services billed this month (TCM, RPM, prolonged services), time was kept distinct: [explain or N/A].

Billing Practitioner Signature: [e-signature with date/time]

(Only include information explicitly documented for this service period. Do not infer content. If required elements—especially consent and moderate/high complexity MDM—are not met, do not bill complex CCM.)