CCM + RPM in one workflow

Deliver Better Chronic Care Between Visits & Build a More Sustainable CCM Program

SmartClinix brings patient enrollment, care planning, monthly coordination, time tracking, documentation, RPM and billing-ready reporting into one connected Chronic Care Management workflow.

CCM hero
Chronic Care Management, Simplified

What CCM Is ?

CCM helps eligible patients with multiple chronic conditions receive structured, coordinated care beyond the traditional office visit. SmartClinix helps practices organize the people, workflows, documentation and technology needed to operate CCM efficiently at scale.

The Problem

Chronic care falls through the cracks between visits

Great intentions, fragmented follow-through. Patients suffer, revenue disappears.

Gaps Between Visits

Chronic patients drift for weeks without contact.

Medication Non-Adherence

Skipped doses lead to avoidable ER visits.

Unbilled Care Minutes

Real work happens but never gets captured.

Silent Deterioration

Risk signals arrive too late to act on.

Care Activity & Time Tracking

Capture and organize qualifying care-management activities against applicable monthly CCM thresholds.

time and trackinag Activity

CCM Capabilities

Patient Enrollment & Consent

Guide eligible patients into the program and maintain participation records within the longitudinal care workflow.

Medication Management

Keep medication lists, adherence discussions, reconciliation activities and follow-up needs connected to the patient’s longitudinal care workflow.

Care Transitions & Coordination

Track referrals, follow-up needs and care transitions across providers and settings.

CMS Compliance

Designed to Support CMS-Aligned CCM Workflows

SmartClinix helps your team organize the documentation, patient engagement, care planning, time tracking and care coordination needed to support compliant CCM operations.

Patient Eligibility

Document chronic-condition eligibility and program enrollment, including applicable duration and clinical-risk criteria.

Initiating Visit

Track initiating-visit requirements when applicable.

Patient Consent

Record CCM consent and program participation, including required patient communication.

Monthly Care Activity

Track qualifying clinical staff and practitioner activities against applicable CCM thresholds.

Care Continuity

Support ongoing access, communication and coordination across the care team.

How it works

CCM Workflow

STEP 1
Identify & Enroll
Identify potentially eligible patients and document enrollment and consent.
Automated
STEP 2
Build the Care Plan
Create a comprehensive, patient-centered electronic care plan based on the patient’s chronic conditions, needs and goals.
Automated
STEP 3
Coordinate Care Monthly
Manage outreach, medication needs, follow-ups, referrals, care gaps and ongoing patient communication.
Automated
STEP 4
Track Care Activity
Capture qualifying care-management activities and cumulative monthly time across the care team.
Automated
STEP 5
Prepare for Billing
Generate structured documentation and billing-ready reports for applicable CCM services.
Automated

Who It’s For

Primary Care

Extend chronic care beyond the office visit while creating a structured monthly care-management program.

Internal Medicine

Coordinate complex, multi-condition patient populations through one longitudinal care plan.

Multi-Specialty Groups

Connect chronic care workflows across providers, specialties and locations.

ACOs / Value-Based Care

Improve visibility into care gaps, patient engagement and chronic-condition management across attributed populations.

Compare

Why teams switch to SmartClinix

Capability
SmartClinix
Legacy CCM Vendor
Generic EHR Module
Care Activity & Time Tracking
Billing-Ready CCM Reports
Integrated RPM workflow
AI-Assisted Risk Insights only if this functionality is currently verified.
24/7 patient access
EHR / Interoperability Options add a footnote that scope varies by environment.
Care coordinator dashboards
CCM Documentation Tracking
CCM CPT Codes

CCM Codes, Clearly Organized

SmartClinix helps practices track CCM time and understand the applicable CPT code thresholds for non-complex and complex chronic care management.

Non-Complex CCM

Standard chronic care management for eligible patients requiring ongoing care coordination.

2 Base Codes
Non-Complex
99490Base Code
Chronic care management, clinical staff time directed by a billing practitioner

First 20 min / calendar month

SmartClinix Thresholds

0–19 min
No Claim
20–39 min
99490
40–59 min
99490 + 99439
60–79 min
99490 + 99439 × 2
Add-on99439
Add-on code

Each additional 20 minutes of clinical staff CCM time

Add-on to 99490 only

Non-Complex
99491Base Code
Chronic care management personally performed by physician/QHP

First 30 min / calendar month

SmartClinix Thresholds

0–29 min
No Claim
30–59 min
99491
60–89 min
99491 + 99437
90–119 min
99491 + 99437 × 2
Add-on99437
Add-on code

Each additional 30 minutes personally performed by physician/QHP

Clinical staff time does not count toward this code.

Complex CCM

For patients requiring complex CCM with moderate/high complexity medical decision-making.

1 Base + 1 Add-on
Complex CCM
99487Base Code
Complex CCM, clinical staff time, moderate/high complexity medical decision-making required
First 60 min / calendar month

SmartClinix Thresholds

0–59 min
No Claim
60–89 min
99487
90–119 min
99487 + 99489
120–149 min
99487 + 99489 × 2

Blue

Non-Complex CCM

Red

Complex CCM

Base Code

Primary CCM code

Add-on Code

Additional qualifying time

CCM coding and reimbursement requirements may vary by payer and patient eligibility. Verify applicable Medicare and payer-specific requirements before billing.
CCM Reimbursement

What Can CCM Reimbursement Look Like?

Estimated average monthly reimbursement for commonly used CCM code combinations.

Illustrative averages — actual reimbursement varies by payer, geography, eligibility, and billing requirements.

Non-Complex • Staff-Led

99490 + 99439 × 2

60 minutes

~$166

Estimated monthly reimbursement

60 min of staff-led CCM
Non-Complex • Physician-Led

99491 + 99437

60 minutes

~$152

Estimated monthly reimbursement

60 min of physician/QHP-led CCM
Complex CCM

99487 + 99489

90 minutes

~$222

Estimated monthly reimbursement

90 min of complex CCM
Onboarding

Go Live in Weeks, Not Months

WEEK 1
100%

Discovery

Panel review · workflow mapping.
  • Kickoff call
  • Config deliverables
  • Success milestone
WEEK 2
80%

Setup

EHR sync · templates configured.
  • Kickoff call
  • Config deliverables
  • Success milestone
WEEK 3
55%

Training

Care team certified on platform.
  • Kickoff call
  • Config deliverables
  • Success milestone
WEEK 4
30%

Go Live

Keep your first month’s revenue

  • Kickoff call
  • Config deliverables
  • Success milestone
Loved by care teams

Outcomes their patients feel

FAQ

Answers, before you ask

SmartClinix supports healthcare interoperability using standards such as HL7 and FHIR, with integration options available for leading EHR platforms. Integration requirements are evaluated based on each organization’s existing environment.

Qualifying care-management activities including calls, notes, messages and other documented interactions can be timestamped and organized against each patient’s monthly CCM activity.

SmartClinix helps organize care plans, consent records, documented care activity and time tracking to support your CCM documentation and billing workflow.

Implementation timing depends on scope, integrations and workflow requirements. SmartClinix provides a structured discovery, configuration, training and launch process.

Most practices go live in 30 days. We handle setup, EHR mapping, staff training, and first-month billing coaching.

Per-enrolled-patient with a modest platform fee. Most practices net 5–10× ROI in the first quarter.

See it in 30 minutes

See How CCM Could Work for Your Patient Population

Bring your current patient volume, care-management workflow and EHR environment. We’ll show you how SmartClinix can support enrollment, care planning, monthly coordination, RPM, documentation and billing workflows.