Care management and remote monitoring
Chronic Care Management (99490 and related codes) and Remote Patient Monitoring (99454, 99445, 99457, 99470): enrollment with the patient's agreement, the care plan, minutes each month, home device readings with alerts, and the month's claims.
Screening questionnaires
PHQ-2, PHQ-9, GAD-7, AUDIT-C and the STEADI falls questions, scored on the record, with a same-day safety task when PHQ-9 question 9 is positive.
Problem list and health history
The front of the chart: diagnoses with ICD-10 codes, past surgeries, family and social history, carried into new notes.
Lab orders and results
Ordering labs through the practice's lab network, results on the record and into the measurements, and reviewing them.
Claims and denials
Insurance claims, the clearinghouse, denials and appeals, and the billing reports.
Referral tracking
Every referral to the practice tracked until the patient is seen, tries to reach them, patients sent elsewhere, and who refers the most.