A welcome change to support the team-based patient care concepts of the medical home is the addition of Current Procedural Terminology (CPT®) codes recognizing the work of complex care coordination for patients with one or more chronic continuous or episodic health conditions, and transitional care management (TCM) services to established patients who require moderate- or high-complexity medical decision-making during transitions from care in a facility setting to a community setting. These codes recognize face-to-face and non–face-to-face services by the physician or other qualified health care professional and clinical staff under his or her direction.

Complex chronic care coordination services include services that implement a care plan for patients who reside at home or in a domiciliary, rest home, or assisted living facility. Patients eligible for these services typically have one or more chronic continuous or episodic health conditions expected to last at least 12 months or for the...

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