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As included in the APCM code descriptors, we are proposing to specify that the care plan is patient-centered which, as for CCM and PCM services, is available timely within and outside the billing practice as appropriate to individuals involved in the beneficiary's care, can be routinely accessed and updated by care team/practitioner, and copy of care plan to patient/caregiver. Providing longitudinal care management, which is an essential element of the delivery of care under an advanced primary care model of care, includes the process of personalized care planning

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