Clinical Summary
Active Diagnoses
Essential Hypertension
I10
Type 2 Diabetes Mellitus, without complications
E11.9
Mild Cognitive Impairment
G31.84
Bilateral Primary Osteoarthritis, Knee
M17.0
Medications
Lisinopril 20mg QAM
Changed Apr 3
Metformin 500mg BID
Amlodipine 5mg QPM
Acetaminophen 500mg PRN
Vitamin D3 2000 IU QAM
Allergies
Penicillin
Sulfa Drugs
Recent Labs
No labs imported yet. Connect lab feed to populate.
Vitals Trend
BMI: 28.4 (last recorded). BP trending data pending RPM enrollment.
Care Management Status
CCM Enrolled
Active
99490
12 min this month
PCM Eligible
Eligible
99424
Qualifying: M17.0, single high-risk condition
ACP Completed
Billed
99497
Session 1 on Apr 5, 2026
LMN Active
Issued
Apr 5 -- wellness services HSA eligible
RPM
Not enrolled
No device yet
TCM
N/A
No recent discharge
Billing Snapshot
$153
This Month
April 2026
$1,836
Annual Projected
Based on current services
This month: CCM 99490 $66 + ACP 99497 $87 = $153
Attestations: 2 this month (all compliant)
Avg review time: 3 min 42 sec (above OIG minimum)
Attestations: 2 this month (all compliant)
Avg review time: 3 min 42 sec (above OIG minimum)
Conversation Memory
12 Sage conversations since enrollment
Care wishes: "No ventilator. Wants to stay home."
Fall risk: 2 falls in 12 months. Morning walk protocol in place.
Caregiver adjustment: Father adapting well to live-in arrangement.
Medication concern: Knee pain not fully managed by acetaminophen.
Decision Ledger
Last 5 entries
Apr 5
Billing
Care
ACP session 1 completed. 99497 billed. Advance directive initiated.
Authorized by: Josh Emdur DO
Apr 5
Billing
LMN issued for wellness services. HSA/FSA eligibility confirmed.
Authorized by: Josh Emdur DO
Apr 3
Medication
Lisinopril increased 10mg to 20mg. BP not at goal on current dose.
Authorized by: Josh Emdur DO
Mar 29
Care
Live-in caregiver (Maria) onboarded. Care plan activated.
Authorized by: Jess Dion (proxy) + Josh Emdur DO
Mar 28
Safety
Fall risk assessment completed. Morning walk protocol established with caregiver.
Authorized by: Josh Emdur DO
Next Actions
Monthly CCM review due: April 30
Consider PCM enrollment 99424
+$88/mo additional revenue
RPM evaluation for BP monitoring
Requires connected device
ACP follow-up session recommended in 6 months
October 2026