I helped to implement billing for CCM in my institution. I am not familiar with a need to determine medical complexity.
Here is a copy of the CMS requirements - as long as these are met the patient qualifies (assuming they have met the other billing requirements such as consent, qualifying visit, etc.
Chronic care management services, provided personally by a physician or other qualified health care professional, 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 death, acute exacerbation/ decompensation, or functional decline, comprehensive care plan established, implemented, revised or monitored; each additional 30 minutes by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)
I along with two other colleagues recently published an article in Nursing Economics which may be helpful for you - the citation is:
Witwer, S.G., Mattson, A., & Jessie, A.T. (2023). Registered nurse billing in primary care. Nursing Economic$, 41 (4), 200-207.
Stephanie G Witwer, Ph.D., RN, NEA-BC, FAAN
Department of Nursing
Emeritus Staff
Original Message:
Sent: 10/28/2023 9:37:00 AM
From: Kathleen Boyle
Subject: RE: Chronic Care Management
I was hoping that Faith Jones would go over that in her talk last week. I am interested in this also
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Kathleen Boyle
Mayo Clinic
Rochester MN
(253)370-8918
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Original Message:
Sent: 10-27-2023 07:55
From: Emily Newbury
Subject: Chronic Care Management
Hello - We are initiating the Chronic Care Management program in our organization and are wondering if anyone would be willing to share their guidance for the nursing staff to determine the moderate to high complexity medical decision making for billing Complex CCM? Thank you in advance.
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Emily Newbury
Gundersen Health System
LaCrosse, WI
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