Chronic Care Management (CCM)
For patients with 2+ chronic conditions expected to last ≥12 months or until death of the patient, and that place the patient at significant risk.
| Code | What it pays for | Notes |
|---|---|---|
| 99490 | First 20 minutes of non-face-to-face CCM by clinical staff under physician supervision, per calendar month | Requires patient consent, a comprehensive care plan, 24/7 access to a clinician, and a designated practitioner. |
| 99439 | Each additional 20 minutes | Up to two units per month. |
| 99487 | Complex CCM — first 60 minutes | For moderate-to-high complexity decision-making. |
| 99489 | Each additional 30 minutes of complex CCM |
How Prepared Patient fits: enrollment, action-plan review, between-visit phone or portal touches, and care-partner coordination all count toward the time threshold when documented.
Principal Care Management (PCM)
For patients with a single high-risk condition (e.g., SCD, CHF, T1D, COPD, HIV).
| Code | What it pays for |
|---|---|
| 99424 / 99425 | Physician or QHP, 30 minutes (and each additional 30 minutes) |
| 99426 / 99427 | Clinical staff, 30 minutes (and each additional 30 minutes) |
How Prepared Patient fits: deep single-condition pathways (SCD, CHF, T1D, COPD, HIV) align with PCM's single-condition focus.
Remote Patient Monitoring (RPM)
For patients using FDA-defined medical devices that transmit physiologic data.
| Code | What it pays for | Common devices |
|---|---|---|
| 99453 | Device setup & patient education (one-time) | BP cuff, scale, glucometer, pulse oximeter, CGM |
| 99454 | Device data, 30 days (requires ≥16 days of data) | |
| 99457 | First 20 minutes of clinical interactive monitoring per month | |
| 99458 | Each additional 20 minutes |
How Prepared Patient fits: the program's daily-tracking pattern (BP, weight, glucose, pulse ox, peak flow) plugs into the device-data feed; review minutes are billable.
Behavioral Health Integration (BHI) & Collaborative Care (CoCM)
| Code | What it pays for |
|---|---|
| 99484 | General BHI, 20 minutes per month |
| 99492 / 99493 / 99494 | CoCM initial / subsequent / additional time |
| G2214 | CoCM, brief monthly |
How Prepared Patient fits: the Depression, Anxiety, PTSD, SUD, and grief-around-chronic-disease curricula are the patient-side education a CoCM team needs.
Transitional Care Management (TCM)
| Code | What it pays for |
|---|---|
| 99495 | Moderate complexity, face-to-face within 14 days of discharge |
| 99496 | High complexity, face-to-face within 7 days of discharge |
How Prepared Patient fits: the Force Field Fact Sheet handoff at discharge + the 7-day call-back script make a clean TCM workflow.
Annual Wellness Visit (AWV)
| Code | What it pays for |
|---|---|
| G0438 | Initial AWV |
| G0439 | Subsequent AWV |
How Prepared Patient fits: name the program in the personalized prevention plan; review uptake at the next AWV.
Social Determinants of Health (SDOH)
Z-codes (Z55–Z65) capture social factors. The onboarding ZIP capture and program intake can support SDOH-aware referrals (transportation, food, housing) coordinated with community resources via PHIT.
ACO / Value-Based Contracts
Most ACO and value-based contracts pay on a mix of:
- Utilization metrics: avoidable ED visits, 30-day readmissions, total cost of care.
- Clinical quality metrics: BP control, HbA1c control, depression remission, screening rates (CRC, breast, cervical, diabetic eye, BMI counseling).
- Patient experience metrics: CAHPS-style measures.
How Prepared Patient fits: the program is built to move the levers most VBC contracts pay on. PHIT exports the panel-level Knowledge · Actions · Confidence deltas, score deltas, and event-rate hooks your committee needs.
Compliance notes
- Every code has documentation, supervision, consent, and (for RPM) device-data requirements. Confirm specifics with your compliance and revenue-cycle teams.
- This page is orientation, not billing advice.
- Patient consent is captured on the patient's own device through the onboarding page — preserve a record of that capture in the chart.
- Sharing or transmitting PHI requires HIPAA-compliant infrastructure. Program data exported to PHIT is anonymous by design; PHI joins happen only inside your covered-entity systems.