The Billing System for
Modern Medical Revenue.

Comprehensive, coordinated care for patients with two or more chronic conditions, improving outcomes and generating predictable revenue.

Chronic Care Management is a Medicare-approved program that supports patients with multiple chronic conditions (e.g., diabetes, hypertension, heart disease, COPD) through ongoing care coordination outside of face-to-face visits. Our platform helps practices document and bill for at least 20 minutes of clinical staff time per patient per month, including care plan creation, medication reconciliation, and coordinated communication across providers.

• Care plan creation and maintenance tailored to each patient's conditions
• At least 20 minutes of non-face-to-face clinical staff time per month
• Medication reconciliation and management
• Coordination with other providers and community resources
• Patient consent and eligibility tracking for CMS compliance

CPT 99490 (20 min), 99439 (additional 20 min), 99487/99489 (Complex CCM)

Monitor patients at home with medical devices and real-time data, enabling timely interventions and better outcomes between office visits.

Remote Patient Monitoring allows healthcare providers to collect and analyze physiologic data from patients in their homes using FDA-cleared devices (e.g., blood pressure monitors, glucometers, pulse oximeters, weight scales). Data is transmitted securely to your team, enabling proactive outreach when readings fall outside set parameters. RPM supports chronic disease management, reduces unnecessary visits, and creates a billable stream while keeping patients engaged in their care.

• Device setup, onboarding, and patient training
• Automatic capture and transmission of vital signs (BP, weight, glucose, SpO2, etc.)
• Out-of-range alerts and clinical workflows for timely intervention
• Minimum 16 days of data per month for Medicare billing compliance
• Integration with EHR and care plans for a unified view

CPT 99453 (setup), 99454 (transmission), 99457/99458 (management time)

Medicare-covered preventive visit that includes a health risk assessment and personalized prevention plan, forming the foundation for proactive care.

The Annual Wellness Visit is a Medicare preventive benefit provided once every 12 months. It includes a Health Risk Assessment (HRA) and the creation or update of a Personalized Prevention Plan (PPPS). The AWV focuses on prevention and detection of cognitive impairment, depression risk, functional ability, and other factors that inform future care. Proper documentation and workflow support help practices deliver these visits efficiently and identify patients who may benefit from CCM, RPM, or other care management services.

• Health Risk Assessment covering demographics, behavioral risks, and activities of daily living
• Documentation of medical and family history and current providers
• Height, weight, BMI, blood pressure; cognitive and depression screening
• Personalized prevention plan with recommendations and goals
• Eligibility verification (once per 12 months, no IPPE or AWV in prior 12 months)

Initial AWV (G0438), Subsequent AWV (G0439)

Focused care management for a single high-risk or complex chronic condition, with 30+ minutes per month of physician or clinical staff time.

Principal Care Management addresses the needs of patients with one serious, complex chronic condition (e.g., one condition that is life-threatening, has high risk of acute exacerbation, or requires unusually complex management). PCM can be billed alongside RPM when time is not double-counted. Services include a single-disease care plan, ongoing management, and at least 30 minutes per calendar month of physician or qualified NPP time, or clinical staff time under physician direction.

• Single chronic condition focus with a dedicated care plan
• At least 30 minutes per month (physician/NPP or clinical staff)
• Eligibility: recent hospitalization, acute risk, or unusually complex management
• Concurrent billing with RPM when time is distinct and documented
• Care plan creation, revision, and coordination with patient and other providers

CPT 99424/99425 (physician/NPP), 99426/99427 (clinical staff)

Support patients in the critical period after discharge from hospital or facility to reduce readmissions and improve outcomes with structured follow-up.

Transitional Care Management covers the 30-day period after a patient is discharged from an inpatient hospital, skilled nursing facility, or other qualifying setting to home or another community setting. TCM includes interactive contact within two business days of discharge, non-face-to-face services (e.g., medication reconciliation, care coordination, patient education), and a face-to-face visit within 7 or 14 days depending on complexity. Effective TCM programs significantly reduce avoidable readmissions and strengthen care continuity.

• Interactive contact (phone, video, or in-person) within 2 business days of discharge
• Review of discharge summary and instructions with patient or caregiver
• Medication reconciliation and management
• Face-to-face visit within 7 days (high complexity) or 14 days (moderate)
• Coordination with follow-up providers and community resources

CPT 99495 (moderate, visit by 14 days), 99496 (high, visit by 7 days)