Services
We design each program around your clinic's workflow and patient population. Below is a general overview - exact eligibility, billing codes, and time requirements are set by CMS and payer policy and can change.
CCM
Chronic Care Management
Non-face-to-face care coordination for patients with two or more chronic conditions expected to last at least 12 months or until death, and that place the patient at significant risk of death, acute exacerbation, or functional decline. Includes a comprehensive care plan, medication reconciliation support, and monthly check-ins between visits.
RPM
Remote Patient Monitoring
Connected devices (blood pressure cuffs, glucometers, pulse oximeters, and similar) transmit readings for structured clinical review between visits, with alerts for values outside a clinician-set range. We use cellular-connected devices, so patients without home Wi-Fi can still participate.
RTM
Remote Therapeutic Monitoring
Monitoring of therapy adherence and response, commonly for musculoskeletal or respiratory conditions, using patient-reported data and structured review.
How these programs are built, generally
This table is illustrative of the general building blocks CMS uses to structure these program types - it is not a fee schedule, a coverage guarantee, or specific billing guidance. Actual codes, time thresholds, and payer rules vary and change; confirm current requirements with your billing staff before submitting claims.
| Program | Care plan / setup | Time / data component | Other building blocks |
|---|---|---|---|
| CCM | Comprehensive care plan, created and kept current | Non-face-to-face clinical staff time, tracked monthly | Medication reconciliation support, 24/7 access to care for urgent needs |
| RPM | Device setup and patient education on use | Data transmission (16+ days of readings in a 30-day period is a common structure) plus monitoring/management time | Clinician-set alert ranges and structured review of readings |
| RTM | Therapy or condition-specific monitoring plan | Device supply/education plus monitoring time, tracked monthly | Patient-reported adherence and response data, reviewed on a structured basis |
Common CPT codes involved
For reference only, not a guarantee of coverage or payment - your payer determines what's actually billable for a given patient.
CCM
99490 · 99439 · 99487 · 99489
RPM
99453 · 99454 · 99457 · 99458
RTM
98975 · 98977 · 98980 · 98981
Also available - ask if needed
Principal Care Management (PCM) for a single high-risk chronic condition, and Behavioral Health Integration (BHI) for care coordination around a behavioral health condition, can also fit some patient populations. We don't lead with these on every clinic - ask during your consult if either sounds relevant to your patients.
A note on reimbursement
Reimbursement depends on your payer mix, patient eligibility, consent, and documentation completeness. We do not guarantee specific revenue, reimbursement amounts, or patient enrollment numbers.