Comprehensive care management for a single high-risk disease services e.g. principal care management at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month with the following elements: one complex chronic condition lasting at least 3 months which is the focus of the care plan the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization the condition requires development or revision of disease-specific care plan the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities
