The Diary® App

The Diary empowers you to better manage your health through meaningful information all in one place – accessible anywhere you are. Get started today!

The Diary Web

Comprehensive health tracking gives you a 360-degree view of your health activities, electronic health record integration, data storage, live support, and easy sharing options.

The Diary CareProTM

The Diary CarePro empowers practices to maintain high quality CCM in office for improved patient outcomes and increased Medicare revenue.

Chronic care management templates, forms and toolkits

Please download and use the following information, and check back regularly for updates!

  • Chronic care management CCM.ConsentForm form template
  • Chronic care management Patient brochure

Contact our Kindness Care team for the following:

  • Provider Success Kit including: an educational presentation, CCM staff guides, and getting started checklist
  • User Guide
  • Administrator Guide
  • Patient Success Kit including: Enrollment Sample letter, Brochure, Consent form, Getting Started Brochure and Termination of service form

If you need further collateral, or documentation support, please let us know at 855-794-6800.

Medicare’s Chronic Care Management

In January of 2015, CMS began allowing providers to bill $42* /patient for chronic care management under CPT code 99490. The code offers medical practices new, reoccurring revenue, often for work they already do while improving outcomes.

The Intent of Chronic Care Management Reimbursement

The Centers for Medicare and Medicaid Services has slowly been transitioning from a fee-for-service to value-based reimbursement model.
Many Medicare patients have numerous chronic conditions, multiple physicians, and a variety of treatment plans. 99490 incentivizes one provider to take the lead and coordinate care with multiple caregivers. This lead receives a hefty reimbursement while increasing efficiencies, and improving care and outcomes.

Provider eligibility for CPT code 99490

Physicians and the following non-physician practitioners may bill the new CCM service:
• Clinical staff working under the general supervision of an eligible practitioner
• Certified Nurse Midwives
• Clinical Nurse Specialists
• Nurse Practitioners
• Physician Assistants

If two practitioners within a practice both provide CCM for the same patient, only one may bill each month.

Chronic Care Management Services

Practitioners must complete a comprehensive care plan and spend 20 minutes per month of non face-to-face time on care coordination activities such as:
• Follow-up calls
• Medication reconciliation
• Monitoring patient-care plans
• Follow-ups after an ER visit
• Consulting with other providers over test results
In addition, the patient must have 24/7 access to the provider

Patient Eligibility for Medicare’s CCM

The patient must:

  • Have two or more chronic conditions
  • The conditions are expected to last at least 12 months (or until death of the patient) and
  • The conditions place the patient at significant risk of death, or functional decline

Patient Copay for Chronic Care Management

Medicare’s current ruling has patients with no secondary with a $8/month co-pay. Most patients will see the value of enhanced patient-provided communication and improved health outcomes. With a drop in number of office visits and decrease in health-related costs, the patient can also see the copay as a net positive.

Patient Consent for Medicare’s CCM

As part of the enrollment package, patients are required to sign the consent form. You can find a copy of this form, and more, in our resources section.