Fillable Form 0415773 0415773 V (Medicare & Medicaid)

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Form 0415773 0415773 V (Medicare & Medicaid)

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Checklist: Chronic care
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests
for Chronic Care Management (CCM) services. Health care providers retain responsibility to submit complete and accurate
documentation.
It is the responsibility of the practitioner who provided the services to ensure the correct submission of documentation.
Note: To print and include this checklist with your medical documentation, click the print button at the end of this form.
Documentation Requirements
Documentation is for the correct beneficiary.
Documentation contains a valid and legible signature.
Documentation includes evidence of a comprehensive care plan being established, implemented, revised or monitored.
Documentation includes evidence of the beneficiary having multiple (two or more) chronic conditions expected to last at least 12
months, or until death of the beneficiary.
Documentation includes evidence that the chronic conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline.
Total time per month spent providing chronic care management services.
Evidence of an initiating visit for new patients or patients not seen within one year prior to commencement of CCM.
Documentation includes evidence of patient consent prior to initiation of CCM services. Consent may be verbal or written.
The availability of CCM services and applicable cost-sharing;
That only one practitioner can furnish and be paid for CCM services during a calendar month.
The right to stop CCM services at any time (effective at the end of the calendar month).
If applicable and required, submitted documentation should include a beneficiary waiver of liability.
Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation
requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is the responsibility of
the provider of services to ensure the correct, complete, and thorough submission of documentation.
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Form 0415773 0415773 V (Medicare & Medicaid)

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Completed 21 July 2020

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