In CY2024 this practice billed $317,532 of remote cardiac device monitoring and $265,365 of chronic care management on 1,139 Medicare patients. In the same year it billed no remote physiologic monitoring, no principal care management, no transitional care management, and — across 6,106 care-management services — not one add-on unit. The clinical model is already proven here. This page models what happens when it is run as a service line.
Source: the companion CoachCare Value Analysis workbook, CY2026 rates for MAC locality AZ • 03102-00.
Your own Medicare claims show you already do — on the device side and, separately, on the care-management side. Two working programs, both running today, neither one marketed anywhere on your website. The argument on this page is about the rungs above and below the ones you are billing, and about the half of the physician bench that is outside the program.
CPT 93294 · 93295 · 93296 · 93297 · 93298 across 7,051 services. Remote monitor evaluation alone runs 3,146 services on 365 patients — 8.6 reads per patient per year. That is a disciplined recurring service with device logistics, data review and monthly billing behind it, not a pilot. Implantable hemodynamic monitors cover another 107 patients.
CPT 99490 on 1,139 Medicare patients across 6,106 services. Consent, care plan, time tracking and monthly billing all exist and all work. This is the single biggest adoption barrier for a remote care program, and it is already behind you.
A Heart Failure Clinic, a Hypertension Clinic, plus cholesterol, arrhythmia and anticoagulation clinics, alongside pacemaker and defibrillator checks and extended-wear rhythm monitoring. Very few cardiology groups commit that explicitly to longitudinal chronic-disease management. Nurse-led, protocol-driven, between-visit care is not a concept this practice needs sold to it.
Every clinician was queried individually against the full CY2024 Medicare care-management code set. Remote physiologic monitoring, principal care management, transitional care management, remote therapeutic monitoring and physiologic data review return no services at meaningful scale on any code — and the CCM add-on rung, 99439, returns none at all against 6,106 base services.
Two numbers frame the whole opportunity. Enrolled care-management patients average 5.4 billed months out of twelve, and the add-on code that captures the second twenty minutes of work is never billed at all. Both are unclaimed revenue against work that is largely already being done — a better-than-two-fold capture gap on the cohort you already manage, before a single new patient is enrolled.
And the program is unevenly held. Four of the eight physicians billing from this practice account for all of the care management; the remote device book sits almost entirely with one. That is not a clinical failure — it is the predictable result of running a service as a personal workflow rather than as a service line. The clinical argument has already been won inside this building. What is missing is the machine around it.
CY2026 is the first year the short-window codes are cleanly billable, and they are built for exactly the patient this practice sees after a hospitalization or a procedure. Nothing about the timing here is defensive.
The old rule needed sixteen days of readings in a thirty-day window before anything was billable. A patient discharged on a Friday, stabilized over two weeks, and stepped down never qualified. 99445 makes that window billable — and post-discharge weight, blood pressure and pulse are where a readmission is either caught or missed.
A shorter management increment beneath the twenty-minute code. It fits the real shape of post-procedure and post-discharge follow-up, where the clinical work is frequent and brief rather than monthly and long.
Verified against the current CMS selection files: this market carries no mandatory-model exposure, so nothing here is compliance-driven. The timing is pure upside — and the infrastructure a service line builds is the same infrastructure any future selection map would require.
Each layer bills on its own and each one feeds the next. Together they turn episodic cardiology into a continuous, documented, recurring service — billed under this practice's own TIN, on its own physicians' orders.
| Service | Codes | ~CY2026 Magnitude | Where it lands here | In the model? |
|---|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every discharge and every post-procedure step-down — at zero services today | No — upside |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 opens the 2–15-day post-discharge window; the whole family is unbilled today | Yes |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 + ~$41 add'l | Monthly review, titration, escalation — the layer the device clinic already does culturally, on a different code family | Yes |
| Principal Care Management | 99424 · 99425 · 99426 · 99427 | ~$79 / ~$57 · ~$60 + ~$50 add'l | Single high-risk cardiac condition managed by a specialist; the clinical-staff codes are the workhorse of a full-service care team | Yes |
| Chronic Care Management + add-on | 99490 · 99439 | ~$62 + ~$47 add'l | Already billed — 1,139 patients, 6,106 services, and the add-on rung never once | No — existing book |
Magnitudes above are national non-facility figures. The value analysis below uses CY2026 rates auto-resolved by MAC carrier and locality for Arizona — AZ • 03102-00 — not these national figures. Arizona is a single statewide payment locality, so all five offices price identically.
The same infrastructure — enrollment, devices, alert triage, escalation, documentation, billing capture — powers each thing this practice already cares about.
This practice runs eClinicalWorks — confirmed from the patient portal host and, independently, from eClinicalWorks Direct messaging endpoints published on its physicians' national provider records. That matters more than it usually would, because CoachCare is the only care management application integrated with eCW that generates claims automatically.
The economics prove the service line pays. This proves it is safe and disciplined. Every reading routes through one shared escalation engine with defined thresholds, defined trends, defined routing and a defined documentation standard — so the practice receives signal, not noise, and never carries surveillance liability it did not agree to.
Both programs in this service line — remote physiologic monitoring and principal care management — route through the same logic. The engine is program-agnostic; the thresholds are set with the practice.
A reading at a critical threshold escalates regardless of whether the patient reports symptoms. There is no wait-and-see branch on a critical value, and no client preference can suppress it.
A non-critical out-of-range reading is worked rather than forwarded: confirm technique, retake, then run a structured symptom check. Most out-of-range readings resolve here, which is exactly why the practice's inbox stays clean.
An out-of-range trend is not a judgement call. It is three consecutive readings at least one hour apart for blood pressure or glucose, or three readings within seven days for heart rate. A confirmed trend escalates on the same footing as a threshold breach.
If the patient cannot be reached, the attempt is documented and a voicemail with a callback request is left — and if the reading was critical or a confirmed trend, the escalation proceeds anyway. Silence never downgrades a clinical finding.
Six fields, every time, so the record is auditable and any event can be reconstructed.
Triggered automatically by any emergency-room visit or hospitalization reported in the last 60 days. This is the readmission-prevention spine, and the mechanism behind the 220 hospitalizations avoided in the forecast below.
Confirm the patient is home and safe, reconcile discharge medications against what is actually in the house, verify follow-up appointments exist, and confirm the monitoring device is set up and transmitting. Clinical alerts documented and escalated per the engine above.
The window where post-discharge decompensation typically declares itself. Symptom review, weight and blood-pressure trend review against the readings already flowing in, adherence check, and escalation on any confirmed threshold or trend.
Confirm the follow-up visit happened, close open issues, verify the patient understands the escalation path, and hand the patient into the longitudinal monitoring panel so the 30-day window closes with continuity rather than a cliff.
Patients do not silently fall out of the program, and the practice is notified at every decision point.
A patient who stops responding is escalated to the practice first, then re-escalated every 30 days — not quietly dropped and not left accruing.
If no instruction is received from the practice, discharge proceeds at 180 days. The practice is notified in every case, and discharges generally process in the first week of the following month.
Clinical discharge criteria, escalation thresholds and routing are the practice's to set. CoachCare executes them consistently and documents the execution. It does not overrule clinical judgement, with the single exception of the emergent floor above.
Because every escalation carries the same six documented fields, any episode can be reconstructed end to end — which is what a payer audit, or a conversation with a referring physician about a patient who did not come back, actually requires.
A 24-month forecast for a two-program service line — remote physiologic monitoring and principal care management — across four offices, 16 referring clinicians, one CoachCare-funded on-site enrollment specialist, and CY2026 rates auto-resolved for MAC locality AZ • 03102-00. It models $4,265,636 of net reimbursement and $1,816,742 net to the practice over 24 months — a 42.59% practice margin (net to the practice ÷ net reimbursement), 41.86% in Year 1 and 42.83% in Year 2. The existing care-management and device books, transitional care management, avoided-admission savings, procedural throughput and all Medicare Advantage and commercial volume are not in these numbers. They sit on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $779,599 | $2,381,959 | $3,161,558 |
| PCM net reimbursement | $267,293 | $836,785 | $1,104,078 |
| Total net reimbursement | $1,046,892 | $3,218,744 | $4,265,636 |
| CoachCare fees | $608,685 | $1,840,209 | $2,448,894 |
| Practice net (after fees) | $438,207 | $1,378,535 | $1,816,742 |
| Practice margin | 41.86% | 42.83% | 42.59% |
| Practice margin is net to the practice ÷ net reimbursement. Includes one on-site enrollment specialist staffed at CoachCare's expense — embedded value already reflected in the fees above, never a deduction from practice margin. | |||
Month-1 practice profit is −$4,030; the first profitable month is month 2. Unit economics are modeled at approximately $95.61 of net reimbursement per RPM patient-month and $89.16 per PCM patient-month, across 33,066 RPM and 12,383 PCM patient-months. The full model is available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months — on top of the existing procedural, imaging, device and care-management book, not instead of it.
A continuous picture of the heart failure, hypertension and post-procedure panels between visits — the physiologic twin of the device data this practice already reviews every month.
Roughly $3.3M of avoided acute cost at $15,000 per admission — value that accrues to patients, to referring physicians and to the hospitals this practice sends cases to.
36,562 care-team hours of monitoring, outreach, escalation and documentation carried by the service line rather than by practice staff.
Every input below is an assumption, and every assumption is arguable. Move them and the 24-month forecast recomputes live. At the modeled settings this engine reproduces the companion Value Analysis workbook exactly — so any disagreement with the output is really a disagreement with an input, which is a much more productive conversation.
"Enrolled services" counts active program enrollments; a patient enrolled in both programs counts twice. At month 24 the model's 3,675 enrolled services correspond to 2,974 enrolled patients once dual enrollment is deduplicated.
CoachCare operates the engine — enrollment outreach, device logistics, 24/7 monitoring, escalation and billing-ready documentation — while this practice's physicians govern the protocols and make every clinical decision. Full-service delivery means launch requires no new practice headcount, and the on-site enrollment specialist in the model is funded by CoachCare.
Agree the escalation thresholds, the routing matrix and the after-hours cover. Settle which patients move to the specialist-appropriate code family and which stay in the existing care-management book. Confirm the eCW version, deployment and licensed modules, and scope the integration build.
Stand up the eCW integration — enrollment flags, order triggers, vital reports into the chart, monthly evidence-of-care attachments, and automated claim generation. Configure device logistics for the Scottsdale, Fountain Hills, Carefree and Wickenburg catchments.
Start where the clinical case is strongest and the existing clinic already exists. Enroll from one or two physicians' panels first, prove the escalation loop and the claim, then open the referral pathway to the rest of the bench.
Extend to the physicians outside the current care-management program, add the post-procedure and post-discharge funnels, and take the capture gap on the existing cohort — the 5.4 billed months and the never-billed add-on rung — as the first tranche of recovered revenue.
Remote care programs fail on operations, not on clinical logic. What follows is the operating record behind the forecast on this page.
Over 400 managed conditions across the platform.
Providers running remote care programs day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than five million claims. Over 100 million vitals recorded and 4 million care actions enabled.