Monthly CCM phone call with patient. Patient reports blood pressure readings at home averaging 144/90 — has been monitoring twice daily as instructed. Reports taking all medications as prescribed. Denies chest pain, shortness of breath, or dizziness. Weight up 2 lbs from last week, likely fluid. Discussed importance of sodium restriction. Patient expressed concern about upcoming cardiology appointment. Educated on what to expect. Reviewed care plan goals — A1C overdue, ordered lab slip. Next CCM contact scheduled for May 2026. Total time: 18 minutes.

Office visit for quarterly chronic disease management. BP 138/86, HR 76, O2 98%. Weight 185 lbs. Reviewed current medication list — no changes to Metformin, Lisinopril, Atorvastatin. Added Jardiance 10mg daily for dual benefit in DM and CHF. Ordered CMP, CBC, HbA1c, BMP. Follow up in 3 months or sooner if BP not improving. Referral to cardiology placed for CHF monitoring.

Monthly CCM call — March. Patient reports feeling fatigued over the past 2 weeks. HR monitoring shows occasional elevated readings. Discussed sleep hygiene, reminded patient to limit caffeine. Reviewed diabetes management — patient successfully tracking glucose daily. Fasting avg 148 mg/dL. Discussed medication refill timing for Metformin. Coordinated with pharmacy for 90-day supply. Updated care plan goals for BP management. Total time: 22 minutes. CPT 99490 — billable.

Coordinated appointment scheduling with Cardiology (Dr. Rivera). Appointment set for Apr 14, 2026 at 2:00 PM. Insurance authorization obtained — ref # AUTH-2026-0892. Patient notified via SMS. Transportation assistance confirmed through non-emergency medical transport.

Monthly CCM — February. Patient reports improved energy. Weight stable at 183 lbs. BP home readings averaging 140/88 — slight improvement. Patient completed dietitian consultation — following reduced-sodium, diabetic-friendly meal plan. Reviewed falls risk assessment — patient declined PT at this time, plan placed on hold. Discussed behavioral health check-in with James Park. Patient agreed to schedule appointment. Total time: 25 min. Billable CPT 99490.

Initial behavioral health assessment. PHQ-9 score: 8 (mild depression). GAD-7: 6 (mild anxiety). Patient reports increased isolation since husband's passing 18 months ago. Discussed grief counseling options. Patient agreed to bimonthly telehealth sessions. Safety plan established. No suicidal ideation. Follow-up in 2 weeks.

January CCM call. Patient recovering from holiday travel fatigue. BP readings slightly elevated at 146/90 — increased antihypertensive dose adjustment discussed with Dr. Walsh. Patient confirmed understanding of new Jardiance prescription — started Dec 30. No adverse effects reported. Glucose readings improving: avg 142 mg/dL fasting. Care plan reviewed and signed by patient. Total time: 20 min. CPT 99490 billable.

CCM enrollment completed. Patient signed consent form (PDF uploaded to documents). CCM program explained — 20-minute monthly calls, care coordination, 24/7 nurse line access. Patient verbalized understanding. Devices ordered: BP monitor, glucometer, pulse oximeter, Bluetooth weight scale. Expected delivery Dec 18–20.