Goals/Outcomes
Client will ambulate 50 feet with walker daily by the end of week 1.
What is a short term goal
Delete repeated ones.
What are immunizations or problems?
Patient will monitor their blood pressure every morning.
What is hypertension?
The code for 20-39 minutes for CCM
What is 99490?
What to do after one month of no contact.
Measurable, Relevant, Time-bound, Specific, and Attainable.
What is a smart goal?
Must have before billing.
What is a signed consent form?
Patient will maintain control of BS AEB recording daily readings and A1C <6.5%
What is Diabetes?
The code for an additional 20 minutes of CCM.
What is 99439?
What to do after three months of no contact.
What is talk to the provider about opt out option?
Client will be independent with ambulation up to 100 feet by Christmas.
What is a long term goal?
Where information put in on that specific DOS goes.
What is the Health Concerns Summary?
Patient will increase GFR level or maintain.
What is Chronic Kidney Disease?
The code for rural health clinic CCM.
What is G0511
This can be done when the patient meets all goals and no longer has concerns.
What is Graduation?
The section where treatment goals and personal goals are documented.
What is the goal summary?
Where the dot phrase must be entered.
A PHQ9 will be completed at each visit.
What is depression?
Patients on Medicare with multiple chronic conditions.
What is an eligible CCM patient?
Done every 3 months, 6 months, or as needed
What is updating the care plan?
A specific measurable change in a patient's status that you expect to occur in response to nursing care.
What is an expected outcome?
Where you would put when a patient is due for diabetic eye exam in the monthly CCM call.
Patient will monitor what foods cause their symptoms and avoid them.
What is acid reflux?
Where to include DME suppliers, emergency contacts, and other providers involved in their care.
What is Other Resources?
This is done after the provider signs the care plan.
What is to mail the patient a copy and document it?