PCM + Geriatrics
Principal Care Management for Geriatrics — athenahealth + CCN Health
Specialized PCM protocols for Geriatrics — integrated with athenahealth, powered by CCN Health. Evidence-based workflows, automated documentation, and Medicare billing.
CCN Health provides a certified Principal Care Management (PCM) integration with athenahealth optimized for geriatrics practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Geriatrics with athenahealth
CCN Health's PCM program integrates with athenahealth to provide geriatrics-specific clinical protocols, device monitoring, and automated Medicare billing for geriatrics patient populations.
Geriatrics Conditions Managed
- Multi-morbidity
- Frailty
- Polypharmacy management
- Fall prevention
- Cognitive decline
- Malnutrition risk
Clinical Protocols
- Comprehensive vital sign monitoring across multiple conditions
- Fall risk assessment and continuous monitoring
- Medication management with polypharmacy review
- Functional status tracking for aging-in-place support
Key Monitoring Metrics
| Metric | Clinical Significance |
|---|---|
| Blood pressure | Tracked and trended for geriatrics management |
| Weight | Tracked and trended for geriatrics management |
| Heart rate | Tracked and trended for geriatrics management |
| SpO2 | Tracked and trended for geriatrics management |
| Activity levels | Tracked and trended for geriatrics management |
| Sleep patterns | Tracked and trended for geriatrics management |
Recommended Devices for Geriatrics
| Device | Use Case |
|---|---|
| Blood pressure monitor | Geriatrics monitoring |
| Weight scale | Geriatrics monitoring |
| Pulse oximeter | Geriatrics monitoring |
| Xandar Kardian sensorless | Geriatrics monitoring |
| Fall detection sensor | Geriatrics monitoring |
Relevant ICD-10 Codes
- R54 (Age-related physical debility)
- R26.x (Abnormalities of gait and mobility)
- Z73.x (Problems related to life management)
- R41.x (Cognitive function symptoms)
Clinical Evidence
Comprehensive geriatric monitoring programs reduce hospitalizations by 20-35% and support longer independent living periods in senior populations.
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 geriatrics practices?
CCN Health's PCM integration provides geriatrics-specific monitoring protocols, automated documentation in athenahealth, and compliant Medicare billing for multi-morbidity and related conditions.
What devices are recommended for geriatrics PCM?
For geriatrics patients, CCN Health recommends blood pressure monitor, weight scale, pulse oximeter based on the specific conditions being managed.
Can PCM data integrate with specialist workflows?
Yes. All PCM data flows into athenahealth and is available for specialist review, care plan updates, and cross-program coordination.
Geriatrics
Geriatrics 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 Geriatrics-specific quality measures.
Clinical Documentation — automated notes that satisfy specialist coding and audit requirements.
Purpose-built for Geriatrics 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 Geriatrics Programs Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside athenahealth
Your program data flows directly into athenahealth — 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.
athenahealth
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 Geriatrics — implementation, billing, and clinical workflows.
Yes. CCN Health integrates with athenahealth so that RPM data flows directly into patient charts, reducing manual documentation and improving care coordination.
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 Geriatrics 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.