From 1 January 2026, all six HCA HealthONE hospitals these clinicians practice in are mandatory participants in the Transforming Episode Accountability Model — CABG included. Thirty days of post-discharge accountability now attaches to hospital CCNs. The cardiologists who actually control those thirty days work in a different clinical record, and across all 44 roster NPIs with CY2024 claims, transitional care management, remote physiologic monitoring and principal care management bill zero.
Source: the companion CoachCare Value Analysis workbook, MAC locality CO • 04112-01.
Read this before you read the numbers: 57.6% of Arapahoe County's Medicare beneficiaries are enrolled in Medicare Advantage. Every figure on this page is a fee-for-service figure priced at the Physician Fee Schedule locality. For the Medicare Advantage majority, payment for these code families is contract-dependent — federal law sets a floor of at least 100% of the Medicare rate, which is not a guarantee that a given plan pays remote monitoring and care management on the same terms, or separately at all. The Medicare Advantage book is larger than the modeled book and is priced contract by contract.
This is not a group that needs convincing that protocol-driven, nurse-run, between-visit care works. Its own Medicare claims show it running exactly that model — at volume, on the device side, with consent and a clinic workflow already in place. The physiologic and care-management layer sitting directly beside it is simply unstaffed and unbilled.
CPT 93294 · 93295 · 93296 · 93297 · 93298, roughly $171,000 of Medicare allowed across up to eleven of the roster's billing clinicians in CY2024 fee-for-service. These patients already have remote data flowing, consent in place and a device-clinic workflow around them. It is the highest-confidence enrollable cohort in the account.
A Protime anticoagulation clinic is named explicitly on the electrophysiology service page. The interventional page carries renal denervation for resistant hypertension; the structural-heart page carries TAVR, transcatheter mitral repair and left-atrial-appendage occlusion. Scheduled non-visit touches under protocol are an established habit here, not a new concept.
Inclisiran (HCPCS J1306) is office-administered, twice-yearly and entirely dependent on the patient coming back. It is the clearest example in the billing record of a therapy whose economics improve when somebody is actively managing the patient between visits — which is precisely what nobody is being paid to do today.
Every provider was queried individually across the full care-management set: remote physiologic monitoring (99453 · 99454 · 99457 · 99458), 99091, chronic care management, principal care management (99424–99427) and transitional care management (99495 · 99496). Zero services, on every code, for every provider.
Scale is not the constraint either: 48 enrolled clinicians — 25 physicians and 23 advanced practice providers — across seven Denver-metro offices, credentialed into six HCA HealthONE hospitals, with rural outreach clinics reaching southern and eastern Colorado and western Nebraska. The operating habit exists. The billable layer on top of it does not.
It is live, it is dated, and CABG is inside it. The obligation sits on hospital CMS Certification Numbers — and the physicians who determine how those episodes end sit outside the entity that carries the risk.
CCN 060100 (HCA HealthONE Aurora, The Medical Center of Aurora) and CCN 060112 (HCA HealthONE Sky Ridge) are both Mandatory participants in the Transforming Episode Accountability Model, CBSA 19740 Denver–Aurora–Centennial, performance period 1 Jan 2026 – 31 Dec 2030, per the CMS TEAM participant list as of 15 Apr 2026.
And it is not only those two. All six HCA HealthONE hospitals where these clinicians hold practice addresses are mandatory participants — CCNs 060014, 060032, 060034, 060065, 060100 and 060112. CBSA 19740 contains 21 TEAM hospitals in total; the division operates six of them.
Coronary artery bypass grafting is one of the five TEAM episode families. TEAM holds the participant hospital accountable for the 30 days after discharge, readmissions included, and expects the hospital to support continuity of care after the patient goes home.
Said plainly: this group has no CMS Certification Number and is not itself a TEAM participant. TEAM participation attaches to a hospital CCN. But the interventional, structural and electrophysiology clinicians in this group are the physician-side actors in those episodes, and the ambulatory follow-up they run is the mechanism by which a 30-day episode either holds or fails.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) make short post-discharge and post-procedure monitoring windows cleanly billable — removing the 16-day floor that previously blocked episodic remote care. That is exactly the window a 30-day episode is decided in.
CMS rulemaking for CY2027 is in progress — remote-monitoring code values can move inside the 24 months modeled here.
This is a named service line with its own owner, P&L and scorecard, not a point solution bolted onto one condition. It follows the Medicare patient from the hospital bed back into the clinic and then across the year — built once, reused for every lever the division already cares about.
| Service | Codes | ~CY2026 Magnitude | Cardiovascular Use | In the model? |
|---|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every cardiac and post-procedure discharge from the six mandatory-TEAM hospitals | No — upside |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 unlocks the 2–15-day post-discharge window inside the episode | Yes |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 + ~$41 add'l | Monthly review, titration, escalation | Yes |
| Principal Care Management | 99424 · 99425 · 99426 · 99427 | ~$60 + ~$50 add'l | A single high-risk cardiac condition expected to last ≥3 months | Yes |
The value analysis below uses CY2026 rates auto-resolved by MAC carrier and locality for zip 80012 — CO • 04112-01.
And the fact that governs this table: these are fee-schedule figures, and 57.6% of Arapahoe County's Medicare beneficiaries are in Medicare Advantage. For that majority, what these code families pay is set by the plan contract. Federal law sets a floor of at least 100% of the Medicare rate; it does not guarantee that any particular plan pays remote monitoring or care management on the same terms, or unbundled.
The same infrastructure — enrollment, devices, alert triage, escalation, documentation, billing capture — powers each thing the division already cares about.
In most accounts the electronic health record is a scoping question — which connector, which version, how long. Here it is the argument. The hospital owns the thirty-day episode. The cardiology group owns the follow-up that decides how the episode ends. And the two do not share a record.
.dot URL pattern across the public site is the health system's corporate web content-management convention, with assets loading from its enterprise web infrastructure. That is evidence about who owns the marketing site — not about the clinical system.The one piece that has to be designed rather than configured: a process or feed that surfaces yesterday's inpatient discharges to the ambulatory team on the day they happen, and starts the two-business-day clock automatically.
Referral into the service line is a single order in eClinicalWorks — not a separate system, a separate login, or a paper form. Enrollment status, program and device are visible at the point of the next clinical decision.
A device on the patient inside the 2–15-day window, with weight, blood pressure and pulse flowing before the point where a readmission becomes likely — and a documented escalation standard behind every reading.
Vitals, evidence of care and care plans returned into the ambulatory chart on a monthly cadence, and the per-patient claim generated by the billing engine rather than assembled by hand — which at a modeled 6,270 active enrollments is the difference between a program that bills what it delivers and one that quietly stops.
Integration capabilities are CoachCare-provided. The value analysis on this page does not assume any particular integration depth: no interface cost, timeline or capability is priced into the forecast, and none is claimed here.
The economics prove the service line pays. This proves it is safe and disciplined. Every reading a patient takes routes through one shared escalation engine with defined thresholds, defined trends, defined routing and a defined documentation standard — so the care team receives signal, not noise, and never carries surveillance liability it did not agree to.
Both programs in this service line — remote physiologic monitoring and principal care management — route through the same logic. The engine is program-agnostic; the thresholds are set with the practice.
A reading at a critical threshold escalates regardless of whether the patient reports symptoms. There is no "wait and see" branch on a critical value, and no client preference can suppress it.
A non-critical out-of-range reading is worked rather than forwarded: confirm technique, retake, then run a structured symptom check. Most out-of-range readings resolve here — which is exactly why the clinic inbox stays clean.
An out-of-range trend is not a judgment call. It is three consecutive readings at least one hour apart for blood pressure or glucose, or three readings within seven days for heart rate. A confirmed trend escalates on the same footing as a threshold breach.
If the patient cannot be reached, the attempt is documented, a voicemail and callback request are left — and if the reading was critical or a confirmed trend, the escalation proceeds anyway. Silence never downgrades a clinical finding.
Six fields, every time, so the record is auditable and any event can be reconstructed end to end.
Triggered automatically by any emergency-room visit or hospitalization reported in the last 60 days. This is the readmission-prevention spine — the mechanism behind the 439 hospitalizations avoided in the forecast below — and it is the operating answer to a 30-day episode obligation that six hospitals in this division now carry.
Confirm the patient is home and safe, reconcile discharge medications against what is actually in the house, verify follow-up appointments exist, and confirm the monitoring device is set up and transmitting. Clinical alerts documented and escalated per the engine above.
The window where post-discharge decompensation typically declares itself. Symptom review, weight and blood-pressure trend review against the readings already flowing in, adherence check, and escalation on any confirmed threshold or trend.
Confirm the follow-up visit happened, close open issues, verify the patient understands the escalation path, and hand the patient into the longitudinal monitoring panel so the 30-day window closes with continuity rather than a cliff.
Patients do not silently fall out of the program, and the care team is notified at every decision point.
A patient who stops responding is escalated to the practice first, then re-escalated every 30 days — not quietly dropped and not left accruing.
If no instruction is received from the practice, discharge proceeds at 180 days. The clinic is notified in every case, and discharges generally process in the first week of the following month.
Clinical discharge criteria, escalation thresholds and routing are the practice's to set. CoachCare executes them consistently and documents the execution — it does not overrule clinical judgment, with the single exception of the emergent floor above.
Because every escalation carries the same six documented fields, any episode can be reconstructed end-to-end — which is what a risk-bearing conversation about a mandatory episode model actually requires.
A 24-month forecast for a two-program service line — remote physiologic monitoring and principal care management — across seven offices, 48 referring providers, one CoachCare-funded on-site enrollment specialist, and CY2026 rates auto-resolved for MAC locality CO • 04112-01. Transitional care management revenue, 30-day episode performance, avoided-admission savings and procedural throughput are not in these numbers. Neither is any Medicare Advantage volume. They are upside on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $1,786,299 | $4,930,973 | $6,717,272 |
| PCM net reimbursement | $537,639 | $1,684,788 | $2,222,426 |
| Total net reimbursement | $2,323,938 | $6,615,761 | $8,939,698 |
| CoachCare fees | $1,348,276 | $3,807,767 | $5,156,043 |
| Practice net (after fees) | $975,662 | $2,807,993 | $3,783,655 |
| Practice margin | 41.98% | 42.44% | 42.32% |
| Includes one on-site enrollment specialist staffed at CoachCare's expense — embedded value already reflected in the fees above, never a deduction from practice margin. | |||
Month-1 practice profit is −$778; the first profitable month is month 2. Fee-for-service only. The full model is available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months — on top of the existing procedural and imaging book, not instead of it. At this volume the claim has to be generated by the billing engine, not assembled by hand.
A continuous clinical picture of the coronary, hypertension and rhythm panels between visits — the physiologic twin of the device data these clinicians already review every week.
Roughly $6.6M of avoided acute cost at an assumed $15K per admission — and direct 30-day episode relief for six mandatory-TEAM hospitals in the same division.
71,844 care-team hours of monitoring, outreach, escalation and documentation carried by the service line rather than by the group's own staff.
Everything in this section is priced at fee-for-service rates for MAC locality CO • 04112-01; the Medicare Advantage majority of this market is not modeled and is contract-dependent.
Every input below is an assumption, and every assumption is arguable. Move them and the 24-month forecast recomputes live. At the modeled settings this engine reproduces the companion Value Analysis workbook exactly — so any disagreement you have with the output is really a disagreement with an input, which is a much more productive conversation.
"Enrolled services" counts active program enrollments; a patient enrolled in both programs counts twice. At month 24 the model's 6,270 enrolled services correspond to 4,927 unique patients once dual enrollment is deduplicated. All outputs are fee-for-service.
CoachCare operates the engine — enrollment outreach, device logistics, 24/7 monitoring, escalation and billing-ready documentation — while the group's physicians govern the protocols and make every clinical decision. Full-service delivery means launch requires no new headcount on the group's side, and the on-site enrollment specialist in the model is funded by CoachCare.
Name the service-line owner, the P&L and the scorecard, and confirm where the decision sits — group leadership, the division, or physician services. Confirm the billing configuration for MAC locality CO • 04112-01. Agree the escalation matrix and discharge criteria. Confirm the hospital-side inpatient record and its interface surface. Commission the Medicare Advantage contract review.
First, the device-monitoring population — already consented, already transmitting, already inside a clinic workflow. Second, post-discharge patients from the mandatory-TEAM hospitals, on the three-touch cadence with short-window RPM placed at discharge. Stand up the daily discharge trigger in parallel; it is the piece that has to be designed rather than configured.
Aurora, Castle Rock, Centennial, Englewood, Greenwood Village, Lakewood and Lone Tree enrolling, with the rural and out-of-state outreach clinics added as the second wave — that is where remote follow-up is worth the most. Monthly scorecard — census, capture rate, revenue per patient-month, escalation volume, readmission signal — reporting to service-line governance.
A documented 30-day post-discharge performance record to take into the division's episode-model conversation, a readmission signal to set against the accountable care organization's PY2024 result, and a standing program rather than a plan when the CY2027 fee schedule lands.
The service line described on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for more than 500,000 patients.
Providers running remote care programs on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced over five million claims.
Over 100 million vitals recorded and more than four million care actions enabled.
CMS's CY2027 Physician Fee Schedule proposed rule, published July 16, 2026, proposes to reprice remote physiologic monitoring. Here is what it reaches, what it leaves alone, and how the operating model behind this service line absorbs it.
CMS's remote-monitoring proposals sit in one code family: RPM. CCM, PCM, and TCM are not part of them. That distinction lands directly on this forecast — PCM carries $2,222,426 of the modeled $8,939,698 in 24-month net reimbursement, and the TCM touch at discharge is outside the proposal entirely. Neither is in scope.
The delivery model has more than one shape, and CoachCare is preparing each so the service line's economics hold wherever the rule settles. One unbundles the program into its parts — SaaS platform, device logistics, and program enablement — priced as components. Another engages CoachCare to run the staffing itself, an MSO-style arrangement in which the practice owns the clinical program and the billing while CoachCare carries the labor model. Neither requires re-architecting the service line described on this page.
Alongside the fee schedule, CMS's ACCESS Model pays remote care as a risk-based per-member-per-month arrangement rather than per code: recurring per-beneficiary payments, half of each one withheld and reconciled against outcome attainment. Cardiometabolic care is among its four clinical tracks. What earns under that structure — controlled pressures, titrated therapy, decompensations caught early — is what this service line is built to produce.
This forecast repriced code by code at CMS's CY2027 proposed values, at this practice's own MAC locality rather than national averages. Same enrollment, same phasing plan — only the rates move.
Both bars run on the same dollar scale, so the red slice is nearly the same width in each — the same dollars, measured against a larger base. The empty track on the top bar is the care-management revenue RPM alone does not include.
Repriced at this locality's own geographic adjusters. The RPM reductions fall almost entirely on practice expense, so the untouched work component carries more weight in some localities than others; the same repricing at national rates would be −8.8% on RPM. Of the $614,449, RPM accounts for $609,774 and the care-management arm for $4,675.
CY2026 versus CMS's published CY2027 proposed values, shown at national non-facility amounts so they can be read against CMS's own tables. This practice's locality-adjusted amounts differ; the repricing above uses the local figures.
| Code family | What CMS proposed | CY2026 | CY2027 proposed | Change |
|---|---|---|---|---|
| In scope — remote physiologic monitoring | ||||
| 99454 / 99445 · device supply | Practice expense recrosswalked | $52.11 | $41.38 | −21% |
| 99457 · management, first 20 min | Direct practice expense removed | $51.77 | $49.59 | −4% |
| 99458 · management, each addl 20 min | Direct practice expense removed | $41.42 | $40.39 | −2% |
| 99453 · setup and patient education | Crosswalked; one-time per patient | $21.71 | $20.03 | −8% |
| Not in scope — the codes the proposal does not reach | ||||
| 99424–99427 · PCM | No structural change proposed | $67.80 | $67.00 | −1% |
| 99495 / 99496 · TCM | Not addressed by the proposal | Outside the remote-monitoring provisions entirely | ||
National non-facility amounts; CY2027 values are CMS's own published proposals in Addendum B of CMS-1848-P. The care-management rows show the lead code in each family; every code in those families moves within about 4% in either direction, which is ordinary annual movement rather than a repricing. The RPM reductions are also phased — section 1848(c)(7) of the Act caps any one code's total-RVU reduction at 19% in a single year, and CMS publishes the affected codes, so CY2027 is a single-digit year for a typical program and the remainder arrives no earlier than CY2028.