Chronic Care Management (CCM)
20-minute monthly CCM programs billing CPT 99490 and 99439.
Care Management Software
Care Management
We build care management platforms that operationalize chronic care management end to end: structured care plans, care-team task routing, and defensible CPT 99490/99439 time capture that survives an audit.
HIPAA-ReadyFHIR R4Role-Based AccessAudit Logged
Trusted by global innovators
What is care management software?
Care management software coordinates longitudinal care for high-risk and chronic patients across nurses, care coordinators, pharmacists and physicians. Agnotic Technologies builds it for providers and digital health teams: FHIR care plans, CCM time tracking, task routing and EHR write-back, with HIPAA safeguards designed in.
The hard part is not the UI. It is modeling FHIR CarePlan, Goal and CareTeam resources so a plan is truly shared, and capturing clinical time precisely enough to meet the 20-minute monthly Chronic Care Management (CCM) threshold.
What it is
How does one shared care plan serve the whole team?
Care management software gives a distributed care team a single, structured plan for each high-risk patient: the goals, interventions, medications, and tasks that keep chronic conditions controlled between visits.
Done well, it captures the clinical time CCM programs bill for, keeps the EHR in sync, and surfaces the patients who need attention. Done poorly, it becomes a parallel spreadsheet no one trusts.
How is care management software built?
A care-management data layer engineered around FHIR CarePlan and defensible time tracking, designed to interoperate with your EHR, not replace it.
What do we build into care management platforms?
Each capability pairs a care-team workflow with the standard or billing rule that makes it defensible.
Structured Care Plans (FHIR CarePlan)
Problem-oriented care plans modeled on FHIR R4 CarePlan, Goal, and CareTeam resources, so each plan is shareable across the EHR and patient app instead of trapped in free-text notes.
CCM Time Tracking (CPT 99490 / 99439)
Automatic, per-activity time capture that rolls up to the 20-minute monthly CCM threshold for CPT 99490 and each additional 20 minutes for 99439, with an immutable audit trail for payer review.
Care-Team Coordination & Task Routing
Role-based task assignment, escalation, and handoffs across nurses, care coordinators, and physicians, with FHIR Task and Communication resources tracking every touchpoint.
Risk Stratification & Panel Views
Rules-based and model-assisted stratification using ICD-10 problem lists and utilization signals to surface the patients whose plans need attention this week.
Consent & Eligibility Management
Captures and versions the beneficiary consent CCM requires, tracks enrollment status, and flags patients who lapse eligibility before a claim is generated.
EHR Write-Back
Care-plan updates and CCM summaries flow back to Epic, Oracle Health (Cerner) or athenahealth via FHIR R4 and HL7 v2, so the chart stays the source of truth.
Where it fits
Which programs do we support?
Principal Care Management (PCM)
Single high-risk condition management with dedicated care plans.
Complex care coordination
Multi-morbidity patients with layered goals and multiple specialists.
Payer care management
Health-plan care teams managing risk-bearing member panels.
Post-discharge follow-up
Transitional care and medication reconciliation after hospitalization.
Behavioral health integration
Collaborative care models that blend physical and behavioral goals.
CCM staffing
How many care managers does a CCM program need?
A CCM program needs enough care managers to cover the monthly minutes its enrolled patients require. Work it out in five lines with your own panel size, minutes per patient and available hours; the lines hold no rates or benchmarks.
Monthly minutes needed
- Enrolled CCM patients x planned clinical staff minutes per patient per month
- Plan at least the 20 minutes CPT 99490 needs for each patient you bill, plus the extra time some patients take
Monthly hours needed
- Monthly minutes needed / 60
Available hours per care manager
- Paid hours per month minus meetings, training, leave and work that does not count toward CCM time
- Use your own figure for each role
Care managers needed
- Monthly hours needed / available hours per care manager, rounded up
Patients per care manager
- Available hours per care manager x 60 / minutes per patient
- Use it to plan enrollment as the panel grows
Where the lines need splitting
- Complex CCM and principal care management patients take different minutes, so run them as separate groups
- After-hours calls and documentation time change the available hours
Is it built for CCM billing?
CCM revenue depends on defensible time capture and enrolled panel size. We build both as first-class concerns instead of afterthoughts.
20 min
Monthly CCM threshold tracked automatically (CPT 99490)
FHIR R4
Care plans modeled on CarePlan, Goal, and CareTeam
Audit trail
Every CCM minute logged with who and when
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through standards-based FHIR APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards and compliance
Which standards do our care management builds use?
FHIRHL7ICD-10CPTHIPAA
Our Process
How do we deliver a care management build?
A phased approach that treats care-plan modeling, billing rules, and EHR interoperability as parallel tracks from day one.
1.
Discovery & Care-Plan Modeling
We map your care programs, CCM billing rules, and target EHRs, then model the FHIR CarePlan, Goal, and CareTeam structures your workflows depend on.
Care-plan first
2.
Core Build & Time Tracking
We build the care-plan engine, task routing, and the per-activity time-capture layer that underpins CPT 99490 and 99439 claims.
Audit-ready billing
3.
EHR Integration
We wire FHIR R4 and HL7 v2 interfaces for problem lists, medications, and care-plan write-back, validated against synthetic and sandbox data.
Interoperable
4.
Rollout & Optimization
Phased go-live with care-team training, billing reconciliation dashboards, and ongoing tuning as enrolled panel size grows.
Measured scale
Program comparison
How do CCM, PCM, RPM and RTM compare?
CCM and PCM pay for care management time against a care plan, while RPM and RTM pay for device data and the management time around it. We build the shared care plan, consent and time tracking once and add each program's evidence rules on top.
| Program | Who it is for | What the software must record | Code family |
|---|---|---|---|
| Chronic care management (CCM) | Patients with multiple chronic conditions | Consent, a care plan, and clinical staff or practitioner minutes per calendar month | 99490, 99439, 99491, 99437, 99487 and 99489 |
| Principal care management (PCM) | Patients with a single high-risk condition | A care plan for that condition and minutes per calendar month | 99424 to 99427 |
| Remote physiologic monitoring (RPM) | Patients sending physiologic readings, such as blood pressure or glucose, from a device | Days of readings in each 30-day period and monthly management time | 99453, 99454, 99445, 99457, 99458 and 99470 |
| Remote therapeutic monitoring (RTM) | Patients on a therapy program, such as respiratory or musculoskeletal care, sending non-physiologic data | Days of data in each 30-day period and monthly treatment management time | 98975 to 98981, plus 98979 and 98984 to 98986 |
Code descriptors and rules change in each year's Physician Fee Schedule, so we check the current year before writing billing logic.
Facts and sources
Which rules shape care management?
Short facts we design around, each linked to its primary source.
Medicare's remote physiologic monitoring codes include CPT 99453, 99454, 99457 and 99458, and the CY 2026 Physician Fee Schedule added 99445 and 99470 for shorter monitoring periods and shorter management time.
Source: Federal Register, November 5, 2025 (CY 2026 Physician Fee Schedule final rule, CMS-1832-F)The CY 2026 Physician Fee Schedule final rule describes separate code sets for chronic care management of multiple chronic conditions and principal care management of a single high-risk condition, and adds RTM codes 98984, 98985, 98986 and 98979 for shorter monitoring periods and management time.
Source: CY 2026 Physician Fee Schedule final rule, 90 FR (govinfo)A HIPAA covered entity may share protected health information with a business associate, such as a software vendor, only under a business associate agreement that commits the vendor to safeguard it.
Source: 45 CFR 164.502(e) and 164.504(e) (eCFR)ONC certification criterion 170.315(g)(10) requires certified EHRs to offer a standardized API for patient and population services based on HL7 FHIR.
Source: 45 CFR 170.315 (eCFR)
Featured case study
Read Case StudyLera Health: compliant women's health platform
Related proof of compliant delivery: for Lera Health we built the privacy-first data layer, longitudinal care workflow, and patient experience end to end. It is not a CCM product, but it demonstrates how we model longitudinal, consent-driven care on a HIPAA-ready foundation.
Why Partner With Us
15-Minute Scoping CallWhy choose Agnotic for care management?
We bring the clinical-domain depth and interoperability experience to ship a care-management platform that bills correctly and survives audit.
Billing-Defensible by Design
CCM time tracking and consent capture are engineered around CMS rules from sprint one, with immutable audit logs, not reconstructed after a denial.
Care-Team Workflow Fluency
We design for how coordinators, nurses, and physicians actually hand off work, so the tool reduces coordination load instead of adding clicks.
Interoperable From Day One
FHIR R4 and HL7 v2 write-back to Epic, Cerner/Oracle Health, and athenahealth is scoped upfront, so care plans reach the chart.
Longitudinal Care Depth
We have built consent-driven, longitudinal care experiences across chronic and women's health, so your team is not educating ours.
Our relevant experience
Care coordination, engineered, not templated.
Frequently Asked Questions
Yes. Care plans and time logs are PHI, so Agnotic signs a business associate agreement before any PHI is shared with our team, and we keep PHI out of development and test environments.
The number of programs, EHR integrations and payers. A first billable program needs FHIR care plans, time tracking and one EHR integration; payer-grade, multi-program platforms add scope. We scope against your programs and EHR mix before quoting.
It depends more on EHR sandbox access and consent workflows than on the care-plan engine. We sequence billing reconciliation early so claims are defensible at go-live, and give you a timeline after the scoping call.
Buy if a packaged CCM tool fits your programs and EHR. Build when you need care plans that write back to your specific EHR, custom stratification, or programs the vendor does not support. We often build the differentiated layer and integrate the rest rather than rebuilding everything.
We integrate via FHIR R4 for problem lists, medications, and CarePlan resources, plus HL7 v2 for legacy feeds. Care-plan updates and CCM summaries write back to Epic, Oracle Health (Cerner) or athenahealth so the chart remains the source of truth.
Every care activity is timestamped and attributed to a staff role, rolled up against the 20-minute CPT 99490 threshold and each additional 99439 increment, and written to an immutable audit log. If a payer requests documentation, the time is reconstructable to the activity level.
Yes. Once time tracking is live, the platform can run the staffing lines on real minutes per patient instead of estimates, by program and by care team, so you see a team nearing capacity before enrollment grows.
Start with the program your clinicians already run, often CCM in primary care or RPM where patients already use devices. The care plan, consent capture and time tracking built for the first program are reused by the next, so later programs add rules rather than a new platform.
Yes. We scope the first release to one workflow, usually one care program with its care plan, consent capture and time tracking against one EHR, and put it in front of your care managers. More programs, payers and integrations follow on the same base.
AI tools help our engineers draft code and tests, but a person reviews every change, and it passes the same automated tests and security checks as any other code, including the tests on CCM time and billing rules. Which tools may see your code or data is agreed with you at the start.
Related Solutions
RPM billing automation for CPT 99453 to 99458RTM billing automation for CPT 98975 to 98981Care Coordination PlatformDisease Management SoftwareRemote Patient MonitoringPopulation Health ManagementEHR Software DevelopmentHIPAA Compliant DevelopmentAPCM billing softwareTelemedicine platform developmentHIPAA requirements for software teams
Ready to build a care management platform that bills correctly?
Share your care programs and EHR landscape. We'll return a phased plan with care-plan modeling, CCM time tracking, and integration sequencing.
contact@agnotic.com
Partnerships
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