Care management programs explained: CCM, PCM, RPM, BHI, APCM, RTM, and TCM.
Medicare offers several care management programs that pay physician practices to organize care between visits. This guide explains what each program is for and how they fit into one care-management workflow — without the CPT-code detail.
The seven care management programs, in plain terms.
Each program targets a different slice of between-visit care. Most practices run several, and a patient is often in more than one.
Chronic Care Management
Ongoing monthly management for patients with multiple chronic conditions — the core between-visit program.
Principal Care Management
Focused management of a single serious, complex chronic condition driving care.
Remote Patient Monitoring
Device readings reviewed by the care team, organized into a follow-up workflow.
Behavioral Health Integration
Behavioral health coordination and follow-up inside a primary care practice.
Advanced Primary Care Management
A practice-level model for team-based care operations across a patient panel.
Remote Therapeutic Monitoring
Therapeutic monitoring information reviewed by the team, with the follow-up organized around it.
Why practices need organized workflows for these programs.
Each program has its own follow-up rhythm, its own documentation, and its own review cadence. Run manually across spreadsheets and disconnected tools, the work fragments — and it gets hard to see who needs attention, what has been done, and what is ready for review. When a patient is in more than one program, that fragmentation multiplies.
- Different follow-up cadence per program
- Documentation spread across tools
- Multi-program patients are hard to see as one picture
How CareOS supports visibility across programs.
CareOS runs every one of these programs on one connected workflow, so a practice can see the between-visit work in one place: what has been done, who needs attention, and whether patients are progressing. It supports documentation readiness and billing review, and keeps every clinical and billing decision with the care team.
For a plain-language look at the code families behind these programs, see the CCM CPT codes and TCM CPT codes overviews. For the official Medicare overview of care management programs, see CMS on Medicare care management services.
Care management programs, answered.
What are care management programs?
They’re Medicare programs that support physician practices in managing care between visits — including CCM, PCM, RPM, BHI, APCM, RTM and TCM. Each targets a different part of between-visit care.
Can a patient be in more than one program?
Yes. A patient may be enrolled in more than one program at a time. CareOS keeps a multi-program patient as one coordinated picture rather than several disconnected views.
Does CareOS handle billing for these programs?
No. CareOS supports documentation readiness and billing review, but it does not submit claims or guarantee reimbursement. Billing decisions stay with your team.
See your care-management programs in one place.
Book a 15-minute conversation and we’ll show how CareOS runs CCM, PCM, RPM, BHI, APCM, RTM and TCM on one connected workflow.