Facebook tracking pixel
Back to Templates
Registered Nurse
30-45 minutes

Standardized Chronic Care Management (CCM) Plan Documentation

The Generic Chronic Care Management (CCM) Plan Notes template is a vital resource for nurses and healthcare professionals dedicated to managing patients with chronic illnesses. This all-encompassing template enables meticulous documentation of patient details, chronic and other medical conditions, social determinants, access to care needs, and time allocated to care management tasks. It aids in precise billing with designated codes for chronic care management services. When integrated with s10.ai, this template guarantees efficient and comprehensive record-keeping, elevating patient care and optimizing communication among healthcare teams.

4,597 uses
4.9/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

(Report Month/Year: [Report Month/Year])
Patient Details:
Name: [Patient Name]
Date of Birth (DOB): [Patient DOB]
Medical Record (MR) : [Medical Record Number]
Type of Residence: [Type of Residence]
Chronic Health Issues:
[List each chronic condition with associated ICD-10 code. Include year of diagnosis if available. Specify current management strategies, including prescribed medications (name, dosage, frequency) and other relevant interventions such as lifestyle modifications, dietary adjustments, monitoring parameters, or specialist involvement.]
Additional Medical Conditions:
[List other medical conditions with ICD-10 codes. Briefly describe management strategies, including medications, therapy, monitoring, or lifestyle adjustments as applicable.]
Additional Needs (Social & Access to Care):
- Transportation Issues: [Describe any transportation limitations affecting the patient’s access to medical care and any arrangements in place, such as reliance on family, medical transport services, or community resources.]
- Social Support: [Outline the patient’s support system, including family, friends, or caregivers involved in their care. Note frequency of visits or level of assistance provided.]
- Nutritional Concerns: [Summarize any dietary restrictions, challenges with meal preparation, or adherence to nutritional guidelines. Include any assistance received for meal planning or access to nutrition services.]
- Cognitive Concerns: [Describe any cognitive difficulties impacting daily functioning or medication adherence. Include strategies for monitoring and managing these issues, such as caregiver oversight or memory aids.]
Physician/QHP Responsible for Care Management:
Primary Physician: [Physician’s Name, Credentials]
Date Initial Plan of Care Developed: [Date]
Date Plan of Care Provided to Patient/Caregiver: [Date]
Time Documentation for Chronic Care Management Activities:
1. [Date] – [Brief description of activity]
- Time (Start-Stop): [Start Time - Stop Time]
- Total Time: [Total Duration]
- Documentation Reference: [Documentation Reference, e.g., call notes, EHR entry, telehealth note]
- Signature: [Staff Signature & Credentials]
2. [Date] – [Brief description of activity]
- Time (Start-Stop): [Start Time - Stop Time]
- Total Time: [Total Duration]
- Documentation Reference: [Documentation Reference, e.g., call notes, EHR entry, telehealth note]
- Signature: [Staff Signature & Credentials]
3. [Date] – [Brief description of activity]
- Time (Start-Stop): [Start Time - Stop Time]
- Total Time: [Total Duration]
- Documentation Reference: [Documentation Reference, e.g., call notes, EHR entry, telehealth note]
- Signature: [Staff Signature & Credentials]
Total Time: [Total Time for the Month]
Billing Codes:
- 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time with moderate or high complexity MDM, per calendar month
- 99489 – Each additional 30 minutes of clinical staff time per calendar month (1 unit)
- 99490 – Chronic Care Management (CCM), at least 20 minutes of clinical staff time per calendar month
Supervising Physician/QHP Signature:
[Supervising Physician’s Name, Credentials]
Date: [Date]
Sample Clinical Note

Example of completed documentation using this template

Reporting Month/Year: November 2024
Patient Information:
Name: John Doe  
Date of Birth (DOB): 15 March 1950  
Medical Record (MR) : 123456789  
Type of Residence: Assisted Living  
Chronic Conditions:
- Hypertension (ICD-10: I10), diagnosed 2010. Managed with Lisinopril 10mg daily, low-sodium diet, and regular blood pressure monitoring.
- Type 2 Diabetes Mellitus (ICD-10: E11.9), diagnosed 2015. Managed with Metformin 500mg twice daily, dietary adjustments, and regular blood glucose monitoring.
Other Medical Conditions:
- Hyperlipidemia (ICD-10: E78.5). Managed with Atorvastatin 20mg daily and dietary modifications.
Other Needs (Social & Access to Care):
- Transportation Issues: Relies on community transport services for medical appointments.
- Social Support: Daughter visits twice a week and assists with medication management.
- Nutritional Concerns: Difficulty adhering to diabetic diet; receives meal planning assistance from a dietitian.
- Cognitive Concerns: Mild cognitive impairment affecting medication adherence; uses a pill organizer and receives oversight from caregivers.
Physician/QHP Responsible for Care Management:
Primary Physician: Dr. Emily Carter, MD  
Date Initial Plan of Care Developed: 1 November 2024  
Date Plan of Care Provided to Patient/Caregiver: 1 November 2024  
Time Documentation for Chronic Care Management Activities:
1. 5 November 2024 – Telehealth consultation  
   - Time (Start-Stop): 10:00 - 10:30  
   - Total Time: 30 minutes  
   - Documentation Reference: Telehealth note  
   - Signature: s10.ai
2. 12 November 2024 – Medication review  
   - Time (Start-Stop): 14:00 - 14:20  
   - Total Time: 20 minutes  
   - Documentation Reference: EHR entry  
   - Signature: s10.ai
3. 20 November 2024 – Care coordination with dietitian  
   - Time (Start-Stop): 09:00 - 09:15  
   - Total Time: 15 minutes  
   - Documentation Reference: Call notes  
   - Signature: s10.ai
Total Time: 65 minutes
Billing Codes:
- 99487 – Complex Chronic Care Management (CCCM), at least 60 minutes of clinical staff time with moderate or high complexity MDM, per calendar month
- 99489 – Each additional 30 minutes of clinical staff time per calendar month (1 unit)
- 99490 – Chronic Care Management (CCM), at least 20 minutes of clinical staff time per calendar month
Supervising Physician/QHP Signature:  
Dr. Emily Carter, MD  
Date: 1 November 2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline chronic care management by providing a structured format for documenting patient information, chronic and other medical conditions, and social needs. It includes fields for detailed management strategies, ICD-10 coding, and time documentation for chronic care management activities, ensuring compliance with billing codes such as 99487, 99489, and 99490. By adopting this template, healthcare professionals can enhance patient care coordination, improve documentation accuracy, and optimize billing processes. Explore this template to efficiently manage patient care plans and facilitate seamless communication among care teams.
Frequently Asked Questions

Common questions about this template and its usage

Ready to transform your practice?

Join thousands of clinicians already using S10.AI to reduce administrative burden and improve patient care.

Cookie Preferences

We use cookies to enhance your browsing experience, analyze site traffic and personalize content.

Standardized Chronic Care Management (CCM) Plan Documentation