Patient Status Icon Legend
: a patient has exceeded an alert threshold set on one or more of their protocol questions
: a patient has met a warning threshold set for one or more of their protocol questions
: the patient is within all set thresholds/guides
: The patient enrolled as a technology patient has never logged into their CCIQ account
: The patient enrolled as a technology patient has never logged into their CCIQ account, and they do not have an email on file, OR the email on file is invalid and needs to be corrected
: Means Locked; the patient’s chart is currently locked to a single staff member for editing. The lock status will automatically be removed when the next scheduled monitoring period is due
: Patient status is paused – a patient is not receiving reminders planned, but is still active and can login to their account
: Means Awaiting Response – the patient has not yet responded to the current monitoring period answers, but it is not yet considered a late status
: Patient is “Late” or “Inactive” in responding to their protocol questions for two or more scheduled monitoring periods
: Finished Monitoring – the monitoring period for a patient has been completed (auto-completed or staff manual set)
: This means review; This check mark will disappear if the patient submits new information or if it’s time for the next monitoring period, indicating that a new review is needed.
How To Remove Lock(Purple) Or Review (Blue Check)
To remove
from a chart once work is completed or to manually reset
a , click on the patient status icon and click Reset.
How To Mark Patient As Reviewed
There are two ways:
Open the patient chart
Where that patient status icon is, click on the downward arrow
Select “Review” and the blue check will now show
OR
Open the patient chart
Click the “Answer” button (can modify & skip answers)
Click the “Mark As Review” button on the bottom right
For more information, please refer to this page: Patient Status Icon Legend
Check or Clear Patient Messages
Open their patient’s chart
Scroll down and click on the “Comments” tab
Click the “Send Message” button to respond to the patient
Click the “Send Message” button when done
Staff can use templates for messages by clicking the “Frequent Messages” dropdown.
After responding to the message, click on the “Clear Alert” button in the top right of the message
For more information, please refer to this page: Patient Messages
Creating A Test Patient
Test patients in ChronicCareIQ are used strictly for training purposes. They allow staff members to become familiar with navigating a patient chart, reviewing workflows, and understanding available features without impacting real patient data.
Open Patient Search
Click Add Patient
Fill out all required fields
In the Last Name field, enter Test
Check the Test Patient checkbox
Click Check for Existing
In the next window, fill out all remaining required fields
Save the test patient record by clicking Add Patient
For more information, please refer to this page: Creating A Test Patient
Enrolling & Activating Patients
Enrolling Patients
On the Monitoring Dashboard, under Other Filters, located under the Select Filters section, select Patients to Enroll
Review the unclaimed patient’s chart and decide whether to:
Activate the patient in the program
Mark them as “Do Not Enroll” (this will flag the patient to never appear on this list again)
Do nothing
Activate Unclaimed Patients from Patient Import
Click on the Patients tab and select Patient Search
Search for an unclaimed patient by either typing in their first and last name or selecting Unclaimed in the Account Status drop-down
Click on the drop-down arrow next to the unclaimed patient’s name & click Activate
In the Activate Patient window, fill out the necessary fields, and click Activate Patient once you’re finished
Manual Add of New Patient
Click on the “Add Patient” button on the monitoring dashboard or on the “Patient Search” tab
Enter the necessary information and click Activate Patient
For more information, please refer to this page: Enrolling & Activating Patients
Add/Enroll Phone Patients
Under the “Select Filter” window, scroll down to “Other Filters” > Select “Patients to Enroll“
A list of potential phone patients (they’re potential CCM candidates by having a significant amount of matched call time within the past 30 days)
CallerIQ must be enabled to view this task
Click on the drop-down near the patient’s name > select “Activate Patient”
Fill out the patient’s info in each of the tabs: Name, Details, Contacts, & Account
Finished, click on “Activate Patient” on the bottom right
If the patient isn’t qualified for CCM enrollment > click on the patient > select “Do Not Enroll,” > click on the “Do Not Enroll” button again
For more information, please refer to this page: Enroll Phone Patients
Convert Patients to Technology
Identify phone patients who have a smartphone or computer, but aren’t reporting data via technology
Navigate to the patient’s chart
Select the “Edit Patient” tab
Click the phone icon next to the patient’s phone number to open the contact preference
Click the “Technology” option
Click the blue “Modify Patient” button at the bottom of the screen to complete
Select the “Actions” tab & choose “Send Communications” from the list of options
From this send communication dialog box, you can send the patient an “Invite/Set Up” via email, text to set up in a browser, or text with a mobile App link to download
Patients can click the link to go directly to the Apple Store or Google Play to download the CCIQ app
Provide the patient with their username (typically their email address) and password (their six-digit birth date (MMDDYYYY))
For patients who prefer to get reminders via email or text message, they can simply sign in via their web browser by clicking the link in the welcome email
For more information, please refer to this page: Convert Patients to Technology
Manual Consent Entry
Navigate to the patient’s chart
Click the Billing Type edit button (pencil and paper icon)
Access the drop-down menu in the consent section to choose the appropriate options
Choose from the Consent drop-down for the different consent options:
Consent Given, Consent Declined, Consent Needed, Externally Documented, and Not-documented (phone patient).
For more information, please refer to this page: Digital Patient Consent
Protocols
Assigning Protocol When Creating A Patient
Click on the Patients Tab and select Patient Search
Click Add Patient and fill out the necessary fields
In the new window, select the protocol from the Protocol or Secondary Protocol drop-down
Assigning Protocols In Patient’s Chart
Open a patient’s chart
Click on Actions and select Edit Patient
In the Modify Patient window, in the Name tab, find the Protocol drop-down
You can type in the drop-down to search for your desired protocol
Click Modify Patient when you’re finished
Assigning Protocol Via Patient Search
Click on the Patients tab & select Patient Search
I recommend setting the Account Status to active & click the Search button
Click on Group Edit & select the patient(s) you want to assign
Click on Commands & select Modify Protocol
In the Protocol or Secondary Protocol drop-down, find & select the protocol you wish to assign
Click Modify when you’re finished
For more information, please refer to this page: Protocols
Patient Goals
Patient goals are used to customize scoring and are an integral part of care planning. As modeled in CCIQ, goals are related to a patient, a measurement type (like BP, weight, blood sugar, etc.), and a specific question.
Goals Panel
To view the goals for a specific patient, navigate to the patient’s chart, go to the “Clinical” or “Care Plan” tab, and select “Goals”.
The list shows all available measurements for your account. It is populated by finding all measurement-questions from the account’s protocols.
Setting Goals
To set a goal, use the context menu for each goal. For a given measurement, one or more goals are possible. This gives staff the flexibility to set upper and lower bounds for a vital. Each goal will be used when setting up custom goals (see below).
Goals Dialog:
When setting up a goal, the “Desired” value is required. This field is used for care planning and for reference on the patient chart and audit log.
The dialog explicitly shows whether measurements should be above or below the desired value. In the example above, the text shows: “Blood Pressure readings should be less than or equal to 120/80”. Use the result dropdown to control whether the value is an upper or lower bound.
Custom Scoring
When setting up custom scoring, it is important to note that it is all or nothing. Whenever custom scoring is ON, the default scoring for the associated question is ignored. A side effect of this is that a goal may be set without an alert. In such a case, the patient would never trigger an alert. Therefore, it is important to set up goals with warnings AND alerts.
Custom Scoring:
For the example above, the desired BP is below 120/80. The software uses that as a starting point for scoring. Such that:
Anything “desired” or below, is scored as a 2.
Anything between 120/80 and 130/80 is scored as a 3
130/80 and above is scored as a 4 (aka warning)
140/90 and above is scored as a 5 (aka alert)
Please Note: CCIQ automatically uses “greater than or equal” for warnings and alerts because the desired goal is “Below”. In the case of “Above”, CCIQ automatically uses “lesser than or equal”. Since that may be a little confusing, the UI explicitly shows a message to describe to staff.
Most measurements only have 1 value. Blood Pressure is a little different since there are two measurements per reading. If either is above the warning thresholds, then a warning is triggered. The same applies to Alerts. To ignore or deemphasize a measurement, just use a really high value.
An example BP setup to ignore Diastolic may look like:
Desired: 120/80
Warning: 130/110
Alert: 140/120
The higher the value for Diastolic, the more irrelevant it becomes in scoring. Setting a value that is one below the Systolic would effectively ignore the Diastolic, which is likely what a lot of clinics will be interested in.
For more information, please refer to this page: Patient Goals
User Tab
PLEASE NOTE: The User Tab is only accessible by users with Admin roles.
Add New User (Provider, Clinical, & Clerical)
Click on the Users tab > click User Summary
Click Add User
Clicking the drop-down arrow will show “Add Provider”, “Add Clinical User”, & “Add Clerical User”
In the Account tab, fill out the necessary fields & set permissions
Checking the Show to Patient would show the phone number extension
Click the Add User button when done
Editing Existing Users/Staff
Click the Users tab > click on User Summary
Click on All Users > click the drop-down arrow next to the patient’s name
Click on Edit User
Once finished, click the Modify User button
PLEASE NOTE: User “Role” for clinical or providers can NOT be edited. Clerical users can be made clinical users. New users will get their login credentials sent to their email automatically
Deactivate, Block, or Delete User
Click on the User tab > click on All Users
Click on the drop-down arrow next to the patient’s name
Click on Edit User
Uncheck the Enabled box (you can also check the Hide User Permanently box to hide that user from the list)
Once finished, click the Modify User button
PLEASE NOTE: the Hide User Permanently box, once checked, can NOT be undone
For more information, please refer to this page: Navigation Training – User Tab
Phone Numbers/Extensions
First, click on the Users tab & select Phone Numbers
Click Add Phone in the top right
In the Phone Type drop-down, you can select the following:
Extension
Phone Number
Label
Enter the phone number or extension (or Label) in the Phone Number/Extension(/Label) field
In the Staff Member drop-down, select the staff member to assign it to
Click the blue Add Phone button once you’re finished
For more information, please refer to this page: CallerIQ: Phone Numbers/Extensions
How To Setup User/Staff Out Of Office Message
PLEASE NOTE: This only accessible to staff users with Admin privileges
Click on your name in the top right
Click on Admin Settings > click Customize Pages
Click on Out of Office Warning > type out your message in the Markdown text box field
Click the Update button
Click Edit Schedule > click on one of the buttons: Add Default, Add Basic, Add Daily, Add Holidays, & Add Custom
Enter the end time and start times in military time > then click the Update button
For more information, please refer to this page: Out of Office Message
Device Setup and Data Syncing
How To Find IMEI/Short Code of A Device
Click on the Devices tab in the patient chart
Click on the gray “i” icon beside the SmartMeter device to see any needed identification numbers for the device
PLEASE NOTE: If you enter an IMEI for an iGlucose device, it will automatically change to the serial number
Assigning NEW Devices From Device List Imported Into CCIQ
Login to CCIQ
Navigate to the patient’s chart (the patient must be active)
Select the Devices tab > Click Assign Device
Select the IMEI device that matches the device being dispensed to the patient.
PLEASE NOTE: If a device is already associated with a patient, the device will NOT show on this list.
Adding NEW devices not imported into CCIQ
Login to CCIQ
Navigate to the patient’s chart (the patient must be active)
Select the Devices tab
Click Add Device
Select Smart Meter from the Manufacturer drop-down menu
Enter the device ID or IMEI (this is contained on the device packaging and on the back label of the device itself)
Click the verify button. This will ping SmartMeter to make sure the device is active and will automatically assign the device type for you. You should get a Valid symbol.
Press the Add Device button to complete the process
PLEASE NOTE: If you get an unknown device message, double-check the IMEI numbers to verify they are correct. If they are, then the device is not mapped to the practice account and CCIQ. Please contact SmartMeter at [email protected] to have them associate the devices appropriately
For more information, please refer to this page: Device Setup & Data Syncing
Flagging Answers & Device Readings For Removal
Search the patient > click to view their patient chart
In the Patient Chart, scroll to the bottom where it says Response Score
Confirm that the wrong reading/score is there > click on the Actions button
In the dropdown, select Flag Answers
Enter the date ranges > click the Preview button
In the Select Action dropdown, click Flag Answer
Select the answer(s)/score(s) you wish to flag > click the Flag button > click ok
Contact CCIQ Support at [email protected] for deletion of flagged answers
For more information, please refer to this page: Flagging and Editing Answers Given
RPM Device Troubleshooting
Having issues with device readings, connectivity, or setup? Visit our RPM Device Troubleshooting page for step-by-step instructions on resolving common issues such as device mismatches, failed transmissions, and connectivity problems.
For more information, please refer to this page: RPM Device Troubleshooting Guide
Modify Date or Time of Patient Answers
Go to the “Actions” tab and select “Flag Answers.”
Put the date range in the choice boxes (ex: 03/06/2023 for this patient)
Choose “Modify Timestamp”
Check the box for the reading you want to update. Update the time and date boxes to the time the patient took the measurement
Click the blue “Modify Timestamp” at the bottom of the dialog box, and you will get a confirmation box.
Click “OK”
The time/date stamp will be updated on the chart and graph
For more information, please refer to this page: Modify Date or Time of Patient Answers
Time Accumulation
Dashboard Time Functionality
Our clinical dashboard is designed in a way to allow you to review individual patient statuses with ease. Patients may submit data for you to review, and this time spent can be considered billable. To ensure your care management program stays compliant, there are a lot of factors involved:
Tracking Eligible Patients:
When a user with a Clinical or Provider role views a patient list on the dashboard, the system begins tracking the time spent viewing each patient.
Recording Dashboard Time:
As time accrues, the software automatically saves the list of patients and the time spent monitoring them. This information is processed overnight to calculate billable time.
Exclusions:
Time is not tracked for patients who fall into the following categories:
Patients who have paused monitoring (unless they’re using a connected vitals device)
Late Patients who haven’t provided any readings for more than 30 days
Patients who have never logged in, don’t have any measurements, or only communicate via phone
Patients who don’t have a billing type or are marked as non-billable
Patients who are no longer being monitored (marked by a checkered flag)
Deceased patients
Rate Limiting and Time Caps:
The system limits tracked time to a maximum of 10 seconds per hour per patient, and caps total time per patient at 30 seconds per day.
Daily Processing and Redundant Data:
Every night, the system processes the tracked data for each staff member. To keep the records clean, the system removes redundant data or entries with no changes.
Adding Offline Time To the Patient’s Chart
Open the patient’s chart
Scroll to the Comments tab and click on it
You can either click on “Add Comment” or “Log Call”
Document any information in the “Call Notes” field
You can also select a template from the “Frequent Comments” or “Frequent Call Notes” drop-down
Make sure you check the “Offline Time” box
In the “Time Adjustment” drop-down, select “Add Offline Time”
Set the duration of the comment or logged call in the “Hours”, “Minutes”, & “Seconds” drop-downs
Select the staff member in the “Staff Member” drop-down
Select the billing type in the “Billing” drop-down
You can also check “Post Date Comment” to schedule a comment or call to be posted on a certain date and time
Click “Add Comment”, “Log Call”, or “Marked as Reviewed”
A “Logged Call” will have a phone icon next to it
PLEASE NOTE: Please be aware that if you post-date a comment for a previous billing month, it could update/change the billing codes generated for that patient during that previous month.
For more information, please refer to these pages: Logging Comments & Logging Calls
Subtracting Offline Time From Patient’s Chart
Open the patient’s chart
Scroll to the “Comments” tab and click on it
You can either click on “Add Comment” or “Log Call”
Document any information in the “Call Notes” field
You can also select a template from the “Frequent Comments” or “Frequent Call Notes” drop-down
Make sure you check the “Offline Time” box
In the “Time Adjustment” drop-down, select “Add Offline Time.”
Set the duration of the comment or logged call in the “Hours”, “Minutes”, & “Seconds” drop-downs
Select the staff member in the “Staff Member” drop-down
Select the billing type in the “Billing” drop-down
You can also check “Post Date Comment” to schedule a comment or call to be posted on a certain date and time
Click “Add Comment”, “Log Call”, or “Marked as Reviewed“
This is often used to subtract any time that should not have been added to the patient’s chart or to correct time accrual mistakes
For more information, please refer to these pages: Logging Comments & Logging Calls
Edit Logged Comments
Open the patient’s chart and click on the “Comments” tab
Locate the logged comment and click the drop-down arrow next to it.
Click “Edit Comment”
Edit the comment’s description as needed
Once you’re finished, click “Modify Comment.”
For more information, please refer to these pages: Logging Comments & Logging Calls
Billing Types In Patient Chart
In the patient’s chart, where their demographics are displayed, you can enable or disable different billing types by clicking the paper and pencil icon next to Billing Type.
In the Patient Billing Type window, you have two options:
Patient is Not Billable – The patient will not be billed for any codes, and no codes will drop in their chart.
Generate Billing Codes For Patient – The patient will be billable, and codes will be generated in their chart.
The Consent Status drop-down indicates whether the patient has given consent for billing. Options include:
Consent Declined
Consent Given
Consent Needed
Externally Documented
Not Documented (Phone Patient)
If the patient is eligible for billing, four columns will be displayed:
Type – Billing type enabled for your CCIQ Account (e.g., RPM, RPM Education, CPM, BHI Base, CCM, PCM, ACPM).
State – Indicates billing eligibility (Enabled, Disabled For Patient, Requires Education (RPM Education), Protocol Not Eligible).
Action – Displays the next step required (Enabled, Disabled, Requires Patient Education (RPM Education), To Enable, Change Patient’s Protocol).
Consent Billing Type – Indicates whether the patient has consented to billing (Yes or No).
For more information, please refer to this page: System Navigation – Patient Chart
How To Manually Bill Out Claims
Click on the Dashboard tab & select Billing
In the Billing Filters section, set your filters and parameters
Where it says Claims, click the drop-down arrow & click Select Records To Mark As Billed
Select the claim(s) that have the Sync Status set to No Claim & scroll back to the top
Click on the Review and Mark as Billed button
Mark as Billed screen will appear and show the billing codes, charges to mark, & number of patients. Click the Mark Billed button
Update Complete screen will appear & you’ll be able to download a CSV file of Billing Records
Click the Ok button
For more information, please refer to this page: Billing Dashboard
BHI, CoCM + CCM Billing
Can a patient be billed for both BHI and CCM in the same month?
Yes, CMS has clarified that Behavioral Health Integration (BHI) and Chronic Care Management (CCM) services can be co-billed for the same patient within the same month, provided all requirements are met.
Can General BHI and CoCM BHI be billed together?
No, General BHI and Psychiatric Collaborative Care Model (CoCM) BHI are NOT co-billable in the same month for the same patient, as per CMS guidelines.
How does the CCIQ billing rules engine assist in billing?
The CCIQ billing rules engine ensures proper tracking of consent, service time, and billing codes to optimize payment outcomes.
Why is CoCM BHI seldom used, even by psychiatric facilities?
Although CoCM BHI is an option, if a patient meets the time requirements for CoCM, it often makes better financial sense to bill for Complex CCM instead, as it reimburses at a significantly higher rate. CMS acknowledges this overlap in eligibility.