CCM Non-Call Activity SOP

PURPOSE: Guide staff on documenting non-call CCM activities, conducting light-touch off-month workflows, and using brief patient check-in scripts — enabling compliant 20-min/month billing while respecting patient privacy preferences.

All three SOPs work together: SOP 1 ensures every minute is captured, SOP 2 structures the off-month workflow, and SOP 3 provides the patient touchpoint that supports compliance

SOP 1 — Documenting Non-Call Activities with Timestamps

Overview CMS allows CCM time to be counted for any care management activity performed by clinical staff, even without live patient contact. Every minute must be documented with a start time, end time, and clear activity documentations.

Billable Non-Call Activities & Timestamp Guidance

⚠️ Compliance Note: Never round time. Log exact start/stop. If interrupted, note it (e.g., '10:04–10:09, paused, resumed 10:11–10:16 = 10 min'). Monthly total must reach 20 minutes.

⚠️Document every interaction as if it will be reviewed by an auditor, attorney, or accreditation body — clear, complete, and timestamped.

  • Open chart → review care plan → make updates → close chart

    Timestamp | example 10:00 AM-10:12 AM

    12 minute

  • Review med list, compare with pharmacy record (call pharmacy), flag discrepancies

    Timestamp | example: 2:15 PM – 2:22 PM

    7 min

  • Call or fax to specialist/pcp office, document outcome.

    Timestamp | example 11:30 AM – 11:38 AM

    8 min

  • Open results, note abnormals, flag for provider, document findings

    Timestamp | example 9:45 AM – 9:52 AM

    7 min

  • Refill request, prior auth follow-up, or formulary check

    Timestamp | example: 3:00 PM – 3:06 PM

    6 min

  • Draft message, review history, send, document time

    Timestamp | example: 1:10 PM – 1:18 PM

    8 min

  • Identify referral need, contact office, confirm appointment

    Timestamp | example: 10:40 AM – 10:49 AM |

    9 min

  • Care Gap Review Review quality measures, identify gaps, document action plan

    Timestamp | example: 4:00 PM – 4:08 PM |

    8 min

  • Review discharge summary, update care plan, schedule follow-up

    Timestamp | example: 9:00 AM – 9:14 AM

    14 min

  • Research or connect patient with social services, transport, meals

    Timestamp | example: 2:45 PM – 2:53 PM

    8 min

SOP 2 — Light-Touch Off-Month Workflow

Overview For patients who prefer not to be called every month, use this structured 10–15 minute workflow in off months. Staff completes all steps internally without requiring a live patient call.

Billable Non-Call Activities & Timestamp Guidance

⚠️Compliance Note: The Compliance Team conducts periodic reviews to ensure all patients receive appropriate care, including those who prefer less frequent contact. We ask all staff to uphold the highest standard of integrity in documenting every activity accurately and completely—to avoid immediate termination.

⚠️Document every interaction as if it will be reviewed by an auditor, attorney, or accreditation body — clear, complete, and timestamped.

  • Open the patient's CCM record. Confirm demographics, emergency contacts, and care team are current. Flag any outdated information for update.

    Timestamp: 2–3 min

  • Read through the active care plan. Verify goals are still appropriate. Note any conditions that may need re-evaluation. Update plan if needed.

    Timestamp: 3–4 min

  • Confirm current medication list matches recent pharmacy/provider records. Flag any new prescriptions or reported side effects from prior notes.

    Timestamp: 2–3 min

  • Check for any scheduled appointments in the next 30 days. If none exist for a chronic condition, flag for follow-up in the call month

  • Send a brief, low-pressure message via patient portal. Use approved script templates (see SOP 3). Document compose/send time.

    Timestamp 2–3 min

  • Log each completed step with start/end time in the CCM activity log. Total should reach 10–15 minutes minimum for the off month

SOP 3— Brief Text & Patient Portal Check-In Scripts

Overview Use these pre-approved templates for off-month outreach. Messages should be warm, brief, and low-pressure — no response required from the patient. Always document the time spent composing and sending.

⚠️Compliance Note: Always personalize scripts before sending — never send a template with unfilled brackets. Portal messages count toward CCM time only when time is logged.

  • Use: Any off month | Portal or Text

    Hi [Patient First Name], this is [Staff Name] from [Organization Name]. We just wanted to check in and let you know we're here if you need anything. No need to respond — we'll be in touch next month for your regular check-in. Have a great [week/month]!

    Document: Time sent, message length, staff name.

    Timestamp: 3 min.

  • Use: Off month, after med review | Portal or Text

    Hi [Patient First Name], a quick note from your care team at [Organization Name]. As a reminder, please continue taking [medication name] as directed. If you have any questions or concerns, feel free to message us here or call us anytime. Take care!

    Document: Medication name referenced, send time, staff initials.

    Timestamp: 3 min.

  • Use: When appointment is scheduled within 30 days | Portal or Text

    Hi [Patient First Name], this is [Staff Name] from [Organization Name]. Just a friendly reminder that you have an upcoming appointment with [Provider Name] on [Date] at [Time]. Please let us know if you need help with transportation or have any questions beforehand.

    Document: Appointment date confirmed, send time, staff name.

    Timestamp: 3 min

  • Use: After ER visit, hospitalization, or specialist visit | Portal or Text

    Hi [Patient First Name], we saw that you recently [had a visit / were seen by a specialist]. We wanted to check in and make sure everything is going okay. You don't need to respond, but if you have any questions or are feeling unwell, please don't hesitate to reach out. We're here for you.

    Document: Visit type noted, send time, chart updated.

    Timestamp: 4 min.

  • Use: When care gap identified during chart review | Portal

    Hi [Patient First Name], this is your care team at [Organization Name]. We noticed it may be time for your [annual labs / flu shot / blood pressure check]. We recommend scheduling this with your provider soon. Let us know if you'd like help setting that up — we're happy to assist!

    Document: Care gap type documented, send time, care plan updated.

    Timestamp: 4 min.

  • Use: Holiday months or slow periods | Portal or Text

    Hi [Patient First Name], wishing you well from your care team at [Organization Name]! We reviewed your care plan this month and everything looks on track. No action needed from you — we'll connect again next month. Stay safe and healthy! Document: Send time, 'no response required' noted in chart.

    Timestamp: 2 min.

Monthly Tracking at a Glance

  • Patient Contact: Portal message or none

    Primary Activities: Chart review, care gap check, portal message, coordination

    Timestamp: 10–15 min

  • Patient Contact: Phone call (20–30 min)

    Primary Activities: Full review, care plan update, med rec, goals

    Timestamp: 30–40 min

Contact Resource & Tools Directors Amanda Lewis or Chrissy Knotts at Support@Mxviii.com if the SOP or Guide you need is missing.

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