PCM + Nephrology
Principal Care Management for Nephrology — ALIS + CCN Health
Specialized PCM protocols for Nephrology — 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 nephrology practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Nephrology with ALIS
For nephrology patients in facilities using ALIS, PCM enables continuous physiological monitoring with data flowing directly into the EHR.
Nephrology Conditions Managed
- Chronic kidney disease (stages 3-5)
- End-stage renal disease
- Nephrotic syndrome
- Hypertensive nephropathy
- Diabetic nephropathy
Clinical Protocols
- Strict blood pressure control (target < 130/80)
- Daily weight monitoring for fluid overload detection
- Threshold alerts for weight gain > 2 lbs/day or BP > 160/100
- Glucose monitoring for diabetic nephropathy patients
Key Monitoring Metrics
| Metric | Clinical Significance |
|---|---|
| Blood pressure | Tracked and trended for nephrology management |
| Daily weight (fluid balance) | Tracked and trended for nephrology management |
| Blood glucose (for diabetic nephropathy) | Tracked and trended for nephrology management |
| SpO2 | Tracked and trended for nephrology management |
| Heart rate | Tracked and trended for nephrology management |
Recommended Devices for Nephrology
| Device | Use Case |
|---|---|
| Blood pressure monitor | Nephrology monitoring |
| Weight scale | Nephrology monitoring |
| Blood glucose meter | Nephrology monitoring |
| Pulse oximeter | Nephrology monitoring |
Relevant ICD-10 Codes
- N18.x (Chronic kidney disease)
- N04 (Nephrotic syndrome)
- I12.x (Hypertensive CKD)
- E11.22 (T2DM with diabetic CKD)
Clinical Evidence
RPM-based blood pressure management in CKD patients has demonstrated slower disease progression and reduced cardiovascular events by 15-25%.
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 nephrology practices?
CCN Health's PCM integration provides nephrology-specific monitoring protocols, automated documentation in ALIS, and compliant Medicare billing for chronic kidney disease (stages 3-5) and related conditions.
What devices are recommended for nephrology PCM?
For nephrology 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.
Nephrology
Nephrology 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 Nephrology-specific quality measures.
Clinical Documentation — automated notes that satisfy specialist coding and audit requirements.
Purpose-built for Nephrology 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 Nephrology 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 Nephrology — 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 Nephrology 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.