PCM for Skilled Nursing
Principal Care Management for Skilled Nursing — Powered by athenahealth + CCN Health
Purpose-built PCM for Skilled Nursing communities. CCN Health integrates directly with athenahealth to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Principal Care Management (PCM) integration with athenahealth designed specifically for skilled nursing facilities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Skilled Nursing with athenahealth
For skilled nursing organizations using athenahealth, Principal Care Management creates a powerful combination of clinical oversight and operational efficiency. CCN Health's integration handles the technical complexity so your clinical team can focus on resident care.
Skilled Nursing Challenges That PCM Addresses
- Managing high-acuity patients with multiple comorbidities
- Reducing 30-day hospital readmission rates
- Meeting CMS quality measures and star ratings
- Maintaining survey readiness with comprehensive documentation
How It Works in Skilled Nursing
- Condition Identification — Identify a single high-complexity chronic condition requiring ongoing management
- Specialist Care Plan — Develop condition-specific management plan with measurable goals
- Focused Monitoring — Disease-specific metrics tracked and trended over time
- athenahealth Integration — Specialist coordination data and care plans sync with athenahealth automatically
- Billing Automation — Time tracking for CPT 99424-99427 documented automatically
Why Skilled Nursing Facilities Choose CCN Health
Readmission Prevention
Continuous monitoring during the critical post-acute window reduces hospital readmissions and improves quality scores.
Quality Measures
Objective vital sign data supports CMS quality reporting and star rating improvement efforts.
Survey Readiness
Comprehensive, timestamped records provide audit-ready documentation for state and federal surveys.
Acute-Level Monitoring
Continuous vital sign capture supports the higher-acuity clinical needs of skilled nursing residents.
Devices for Skilled Nursing PCM
| Device | Use Case | Resident Experience |
|---|---|---|
| Condition-Specific Devices | Targeted monitoring | Devices matched to the principal condition |
| Specialist Dashboard | Disease tracking | Trend views for condition-specific metrics |
Clinical Benefits for Skilled Nursing
Chronic Disease Management
Monitor residents with conditions like post-surgical recovery, heart failure, pneumonia, COPD exacerbation. Trending data helps clinical teams adjust care plans before conditions deteriorate.
Transition of Care Support
When residents return from hospital stays, PCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Skilled Nursing
CCN Health automates Medicare PCM billing documentation for qualified residents:
| 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 resident: $70+
Frequently Asked Questions
Does CCN Health integrate with athenahealth for skilled nursing PCM?
Yes. CCN Health's certified athenahealth integration enables bi-directional data flow specifically designed for skilled nursing workflows.
What is the implementation timeline for skilled nursing?
Most skilled nursing facilities are fully operational within 4 weeks, including integration setup, nursing staff training, and device deployment.
How does PCM billing work in skilled nursing?
CCN Health automatically documents the required data for 99424, 99425, 99426, 99427. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Skilled Nursing
| Week | Activity |
|---|---|
| 1 | Discovery call and athenahealth configuration review |
| 2 | Technical integration setup and testing |
| 3 | Nursing staff training and device deployment |
| 4 | Pilot launch with select residents |
| 5+ | Full facility rollout and optimization |
Discovery call — we learn your workflows, EHR setup, and resident population.
CCN's AI engine configures optimal alert thresholds and EHR data mapping around your facility's patterns.
Go live with AI-powered monitoring, automated documentation, and billing — your team stays focused on care.
No one-size-fits-all templates. Every integration is configured for how your Skilled Nursing actually operates.
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 Skilled Nursing Facilities 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 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.
Skilled nursing facilities use RPM to continuously monitor residents' vitals, enabling early detection of decline, reducing hospital transfers, and supporting compliance with quality reporting requirements.
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 Skilled Nursing?
See how CCN Health can improve resident outcomes, preserve independence, support family engagement, and generate new Medicare revenue — all within the EHR your staff already uses.