Chronic Condition Management

In 2015 Medicare added an ongoing chronic care management program for patients with a minimum of two chronic conditions. Medicare has made adjustments over the years to the chronic care management program. One such change Medicare has added is principal care management code for patients with one single high-risk condition (one complex chronic condition).  The federal agency intended for the codes to cover to costs of creating and updating care plans, reviewing results, communicating with other providers outside of the practice, and regularly adjusting treatment regimens. Medicare came up with this code to keep patients healthy and avoid hospitalization or acute exacerbation due to your chronic conditions.

Dr. Fiorentino’s program consist of a team-based care approach since non-physician staff can perform some of the services. Various services are implemented “behind the scenes” for our chronic care management patients to ensure that the appropriate treatment plan is being implemented and that the patient’s chronic care needs are attended to. Sometimes extra steps will be initiated regarding medication, communication with other physician offices, support staff, lab companies, diagnostic facilities, or pharmacies – especially in such instances as prior authorizations. We will also maintain contact with our CCM patients on a regular basis by the phone and electronically via our patient portal. We encourage caregivers and support staff, including home health facilities, to maintain direct contact with our chronic care management team in order to facilitate and implement appropriate health care management.