CCM + Geriatrics
Chronic Care Management for Geriatrics — Epic + CCN Health
Specialized CCM protocols for Geriatrics — integrated with Epic, powered by CCN Health. Evidence-based workflows, automated documentation, and Medicare billing.
CCN Health provides a certified Chronic Care Management (CCM) integration with Epic optimized for geriatrics practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Geriatrics with Epic
For geriatrics patients in facilities using Epic, CCM enables continuous physiological monitoring with data flowing directly into the EHR.
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 |
|---|---|---|
| 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 geriatrics practices?
CCN Health's CCM integration provides geriatrics-specific monitoring protocols, automated documentation in Epic, and compliant Medicare billing for multi-morbidity and related conditions.
What devices are recommended for geriatrics CCM?
For geriatrics patients, CCN Health recommends blood pressure monitor, weight scale, pulse oximeter based on the specific conditions being managed.
Can CCM data integrate with specialist workflows?
Yes. All CCM data flows into Epic 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 Epic
Your program data flows directly into Epic — 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.
Epic
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 Geriatrics — implementation, billing, and clinical workflows.
Yes. CCN Health integrates with Epic via secure APIs, enabling RPM device data and care management documentation to flow into Epic's enterprise health records.
CCN Health transmits device readings and care coordination notes to Epic through FHIR-based APIs, ensuring clinical data is available within existing Epic workflows.
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 TeamGet Started
Ready to bring Chronic 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.