The billing system for modern patient care.

Monthly care coordination for patients with 2+ chronic conditions.

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 coordination with other providers
• Patient consent and eligibility tracking for CMS compliance

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

Device-powered monitoring between visits with actionable alerts.

Remote Patient Monitoring allows providers to collect and analyze physiologic data from patients at home using FDA-cleared devices (e.g., blood pressure, glucometers, pulse oximeters). Data is transmitted securely, enabling proactive outreach when readings fall outside set parameters. RPM supports chronic disease management and creates a billable stream while keeping patients engaged.

• Device setup, onboarding, and patient training
• Automatic capture and transmission of vital signs
• Out-of-range alerts and clinical workflows
• Minimum 16 days of data per month for Medicare billing

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

Preventive visit with HRA and personalized prevention plan.

The Annual Wellness Visit is a Medicare preventive benefit once every 12 months. It includes a Health Risk Assessment (HRA) and creation or update of a Personalized Prevention Plan. The AWV focuses on prevention, cognitive and depression screening, and factors that inform future care. Proper documentation helps practices deliver these visits efficiently and identify patients for CCM, RPM, or other care management.

• Health Risk Assessment and prevention plan
• Documentation of history, BMI, screenings
• Eligibility verification (once per 12 months)

Initial AWV (G0438), Subsequent AWV (G0439)

Focused management for one complex chronic condition.

Principal Care Management addresses patients with one serious, complex chronic condition. PCM can be billed alongside RPM when time is not double-counted. Services include a single-disease care plan 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 dedicated care plan
• At least 30 minutes per month (physician/NPP or clinical staff)
• Concurrent billing with RPM when time is distinct

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

High-touch follow-up after hospital or SNF discharge.

Transitional Care Management covers the 30-day period after discharge from an inpatient hospital, SNF, or other qualifying setting. TCM includes interactive contact within two business days of discharge, non-face-to-face services (e.g., medication reconciliation, care coordination), and a face-to-face visit within 7 or 14 days depending on complexity. Effective TCM reduces avoidable readmissions.

• Interactive contact within 2 business days of discharge
• Medication reconciliation and face-to-face visit by day 7 or 14
• Coordination with follow-up providers and community resources

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