CCM + Pulmonology
Chronic Care Management for Pulmonology — Epic + CCN Health
Specialized CCM protocols for Pulmonology — 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 pulmonology practices, featuring sensorless monitoring technology. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Pulmonology with Epic
CCN Health's CCM program integrates with Epic to provide pulmonology-specific clinical protocols, device monitoring, and automated Medicare billing for pulmonology patient populations.
Pulmonology Conditions Managed
- COPD
- Chronic asthma
- Pulmonary fibrosis
- Sleep apnea
- Post-COVID respiratory conditions
Sensorless Monitoring for Pulmonology
Xandar Kardian XK300 uses 60GHz radar waves to detect micro-movements of the chest wall from breathing and heartbeat, capturing vital signs without any physical contact.
This technology is particularly valuable for pulmonology patients because it provides heart rate, respiratory rate, presence/absence detection data that directly informs clinical decision-making.
Clinical Protocols
- Continuous SpO2 and respiratory rate monitoring
- Threshold alerts for SpO2 < 88% or RR > 24
- Exacerbation detection via trending respiratory data
- Sleep apnea screening with overnight monitoring
Key Monitoring Metrics
| Metric | Clinical Significance |
|---|---|
| SpO2 levels | Tracked and trended for pulmonology management |
| Respiratory rate | Tracked and trended for pulmonology management |
| Peak expiratory flow | Tracked and trended for pulmonology management |
| Heart rate | Tracked and trended for pulmonology management |
| Sleep quality and apnea events | Tracked and trended for pulmonology management |
Recommended Devices for Pulmonology
| Device | Use Case |
|---|---|
| Pulse oximeter | Pulmonology monitoring |
| Xandar Kardian sensorless (RR) | Pulmonology monitoring |
| Blood pressure monitor | Pulmonology monitoring |
| Sleep monitor | Pulmonology monitoring |
Relevant ICD-10 Codes
- J44.x (COPD)
- J45.x (Asthma)
- J84.x (Pulmonary fibrosis)
- G47.3x (Sleep apnea)
Clinical Evidence
Remote monitoring of COPD patients reduces exacerbation-related hospitalizations by 20-30% and enables earlier intervention during acute episodes.
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 pulmonology practices?
CCN Health's CCM integration provides pulmonology-specific monitoring protocols, automated documentation in Epic, and compliant Medicare billing for copd and related conditions.
What devices are recommended for pulmonology CCM?
For pulmonology patients, CCN Health recommends pulse oximeter, xandar kardian sensorless (rr), blood pressure monitor 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.
Pulmonology
Pulmonology 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 Pulmonology-specific quality measures.
Clinical Documentation — automated notes that satisfy specialist coding and audit requirements.
Purpose-built for Pulmonology 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 Pulmonology 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 Pulmonology — 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.
Sensorless monitoring uses under-mattress or contactless sensors to track vitals like heart rate, respiratory rate, and sleep patterns without the resident wearing or operating any device.
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 Pulmonology 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.