CCM + Nephrology
Chronic Care Management for Nephrology — athenahealth + CCN Health
Specialized CCM protocols for Nephrology — integrated with athenahealth, powered by CCN Health. Evidence-based workflows, automated documentation, and Medicare billing.
CCN Health provides a certified Chronic Care Management (CCM) integration with athenahealth optimized for nephrology practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Nephrology with athenahealth
Nephrology practices managing chronic kidney disease (stages 3-5) and end-stage renal disease can leverage CCN Health's CCM integration with athenahealth for disease-specific monitoring, automated documentation, and compliant billing.
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 |
|---|---|---|
| 99490 | ~$62/mo | 20+ minutes of clinical staff time per month |
| 99491 | ~$83/mo | 30+ minutes of physician/QHP time per month |
Monthly potential per patient: $62+
Frequently Asked Questions
How does CCM support nephrology practices?
CCN Health's CCM integration provides nephrology-specific monitoring protocols, automated documentation in athenahealth, and compliant Medicare billing for chronic kidney disease (stages 3-5) and related conditions.
What devices are recommended for nephrology CCM?
For nephrology patients, CCN Health recommends blood pressure monitor, weight scale, blood glucose meter based on the specific conditions being managed.
Can CCM data integrate with specialist workflows?
Yes. All CCM data flows into athenahealth 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 athenahealth
Your program data flows directly into athenahealth — no exports, no manual entry, no disruption to your clinical workflow.
Care Coordination
Calls, Assessments, Care Plans
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
Chronic conditions, medications, and problem lists from your EHR
Care Plan Updates
Treatment plans and goals sync bi-directionally
Contact Logging
Phone calls and check-ins documented with timestamps
Medication Reconciliation
Current medication lists kept in sync across platforms
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99490/99491 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
Chronic Care Management (CCM)
3 billing codes
First 20 minutes of clinical staff time for CCM services
~$62
Monthly
Each additional 20 minutes of CCM clinical staff time
~$47
Monthly (additional)
First 30 minutes of physician/QHP time for complex CCM
~$83
Monthly
Common Questions
Frequently Asked Questions
Everything you need to know about Nephrology — 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.
CCM is a Medicare program that reimburses providers for non-face-to-face care coordination for patients with two or more chronic conditions, billed under CPT codes 99490, 99439, and 99491.
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 Chronic 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.