PCM + Internal Medicine
Principal Care Management for Internal Medicine — ALIS + CCN Health
Specialized PCM protocols for Internal Medicine — integrated with ALIS, powered by CCN Health. Evidence-based workflows, automated documentation, and Medicare billing.
CCN Health provides a certified Principal Care Management (PCM) integration with ALIS optimized for internal medicine practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Internal Medicine with ALIS
For internal medicine patients in facilities using ALIS, PCM enables continuous physiological monitoring with data flowing directly into the EHR.
Internal Medicine Conditions Managed
- Hypertension
- Diabetes
- Heart failure
- COPD
- Chronic kidney disease
- Metabolic syndrome
Clinical Protocols
- Multi-condition monitoring with condition-specific thresholds
- Preventive care integration with annual wellness visits
- Medication titration based on objective trending data
- Chronic disease management across multiple organ systems
Key Monitoring Metrics
| Metric | Clinical Significance |
|---|---|
| Blood pressure | Tracked and trended for internal medicine management |
| Blood glucose | Tracked and trended for internal medicine management |
| Weight | Tracked and trended for internal medicine management |
| SpO2 | Tracked and trended for internal medicine management |
| Heart rate | Tracked and trended for internal medicine management |
| Temperature | Tracked and trended for internal medicine management |
Recommended Devices for Internal Medicine
| Device | Use Case |
|---|---|
| Blood pressure monitor | Internal Medicine monitoring |
| Weight scale | Internal Medicine monitoring |
| Blood glucose meter | Internal Medicine monitoring |
| Pulse oximeter | Internal Medicine monitoring |
| Dexcom G7 CGM | Internal Medicine monitoring |
Relevant ICD-10 Codes
- I10 (Essential hypertension)
- E11.x (Type 2 diabetes)
- I50.x (Heart failure)
- J44.x (COPD)
- N18.x (CKD)
Clinical Evidence
Internal medicine practices implementing RPM programs see 15-25% improvements in chronic disease management quality metrics and patient satisfaction scores.
Billing & Reimbursement
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99424 | ~$70/mo | 30+ minutes of clinical staff time per month |
| 99425 | ~$56/mo | Each additional 30 minutes of clinical time |
| 99426 | ~$80/mo | 30+ minutes of physician/QHP time |
| 99427 | ~$64/mo | Each additional 30 minutes of physician time |
Monthly potential per patient: $70+
Frequently Asked Questions
How does PCM support internal medicine practices?
CCN Health's PCM integration provides internal medicine-specific monitoring protocols, automated documentation in ALIS, and compliant Medicare billing for hypertension and related conditions.
What devices are recommended for internal medicine PCM?
For internal medicine patients, CCN Health recommends blood pressure monitor, weight scale, blood glucose meter based on the specific conditions being managed.
Can PCM data integrate with specialist workflows?
Yes. All PCM data flows into ALIS and is available for specialist review, care plan updates, and cross-program coordination.
Internal Medicine
Internal Medicine Protocols — clinical workflows configured to evidence-based guidelines and risk thresholds.
Specialist Coordination — automated alerts and reporting to referring specialists and primary care teams.
Outcome Tracking — longitudinal vitals data mapped to Internal Medicine-specific quality measures.
Clinical Documentation — automated notes that satisfy specialist coding and audit requirements.
Purpose-built for Internal Medicine workflows — integrated with the EHR your facility already uses.
Book a Discovery CallAI-Powered Alerts
Pattern recognition catches changes early
Smart Workflows
Automated routing and documentation
Automated Compliance
Real-time audit trail and billing validation
Advanced intelligence working behind the scenes — faster processing, smarter alerts, effortless documentation.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Internal Medicine Programs Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside ALIS
Your program data flows directly into ALIS — no exports, no manual entry, no disruption to your clinical workflow.
Specialist Data
Condition Monitoring, Referrals
AI-Powered Platform
Intelligent data routing, anomaly detection, and automated documentation — working behind the scenes.
ALIS
Charts & Care Plans
What Flows Between Systems
Patient Demographics
High-risk conditions, specialist data, and medications
Condition Tracking
Disease-specific metrics monitored and trended
Specialist Coordination
Referral data and specialist notes synchronized
Care Plans
Condition-specific treatment plans inform monitoring
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99424/99425/99426/99427 records generated automatically
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Infrastructure
Medicare Billing
Automated Medicare billing documentation — every qualifying encounter captured and coded.
Medicare Billing
Principal Care Management (PCM)
2 billing codes
First 30 minutes of clinical staff time for PCM
~$70
Monthly
Each additional 30 minutes of PCM clinical staff time
~$54
Monthly (additional)
Common Questions
Frequently Asked Questions
Everything you need to know about Internal Medicine — implementation, billing, and clinical workflows.
Yes. CCN Health integrates with the ALIS platform so that RPM readings sync directly into resident records, streamlining clinical workflows for senior living communities.
CCN Health transmits device data to ALIS through a secure API, ensuring vitals are available to caregivers inside the EHR they already use every day.
PCM focuses on patients with a single high-risk chronic condition, billed under CPT codes 99424 and 99425, covering care coordination and management services.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Talk to Our Team
Get Started
Ready to bring Principal Care Management to your Internal Medicine program?
See how CCN Health can improve patient outcomes, support specialist coordination, and generate new Medicare revenue — all within the EHR your staff already uses.