Guides for running care management operations
Practical, operator-informed explanations of how chronic and longitudinal care programs actually work — the workflows, the documentation, and where practices lose time. Written for physician practices, not search engines.
Chronic Care Management
What is chronic care management?
The program concept explained — what CCM is, who it’s for, and what a practice takes on to run it.
CCM workflow guide
The monthly operational rhythm of a CCM program, step by step, from enrollment to documentation review.
CCM vs PCM
How to decide between chronic care management and principal care management for a given patient.
Programs explained
What is PCM?
Principal care management for a single high-risk condition — how it differs from CCM.
What is TCM?
Transitional care management and the time-sensitive post-discharge window.
What is APCM?
Advanced primary care management and longitudinal, panel-wide care.
Care management programs, explained
A plain-language guide to CCM, PCM, RPM, BHI, APCM, RTM and TCM, and how the programs fit together.
Operations & workflow
Care gaps in chronic care management
Why care gaps open between visits, and how connected workflows help teams see and close them — with human review.
CCM service provider vs software
Two operating models for running a CCM program — outsourced nursing versus software your team operates — and how to choose.
New guides
Medicare Chronic Care Management Platform
What practices should look for in a Medicare CCM platform — workflow, care plans and documentation context.
Post-Discharge TCM Software
How software helps teams track transitional care follow-up after a hospital discharge.
PCM Software for Specialists
Organizing principal care management workflows for a single complex condition.
Care Management Tracking System
Making between-visit care easier to see across programs.
CPT codes & documentation
Care Management CPT Codes
A plain-language overview of the CPT codes used across CCM, PCM, RPM, BHI, APCM, RTM and TCM, and what practices organize before billing review.
CCM CPT Codes
The CPT codes chronic care management programs use most, explained at a high level, with the documentation CCM teams keep review-ready.
TCM CPT Codes
TCM CPT codes 99495 and 99496 explained at a high level, with the post-discharge documentation transitional care teams keep reviewable.
Care Management Documentation Checklist
A practical checklist for keeping program context, care plans, time and review status organized and reviewable.
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