What is a Medicare Annual Wellness Visit? A Medicare Annual Wellness Visit (AWV) is a preventive screening used to identify gaps in care.

Transitional Care Management (TCM) was developed by the Centers for Medicare & Medicaid Services (CMS) mainly for adults older than 65. However, the model presented through its requirements and the CPT codes that CMS reimburses is also accessible to clinicians serving patients under 65. Additionally, many commercial payors cover transitional care through various products and arrangements, which we will explore.

Care coordination includes organizing patient activities and services across multiple providers. The approach prioritizes communicating all relevant information to the participants involved in the person’s care. Its overall objective is to fulfill an individual’s care needs and preferences through high-quality, personalized engagement.

One of the powerful aspects of Medicare care management programs is that some are designed to work together. A primary example is offering Chronic Care Management (CCM) alongside Remote Patient Monitoring (RPM).

What is Transitional Care Management? Transitional Care Management (TCM) helps patients in the first 30 days following a hospital discharge. Covered by Medicare Part B, providers should learn what CPT billing codes are used for TCM in order to optimize care delivery and avoid denied claims.

The Centers for Medicare and Medicaid Services (CMS) has updated the 2025 Final Rule for Chronic Care Management (CCM). For 2025, there were no major changes to the CCM program rules and regulations in CMS’s Final Rule, but for the first time, Rural Health Clinics and Federally Qualified Health Centers can now bill the CCM CPT codes just like other fee-for-service practices. There are also updated reimbursement rates for the CPT codes.

What is Chronic Care Management? Chronic Care Management (CCM) is a preventive health program that helps patients mitigate their chronic conditions. As covered by Medicare Part B, providers should understand what CPT billing codes matter to the program and how they are used. This can help your organization avoid denied claims and enhance care.

What is Remote Patient Monitoring? With Remote Patient Monitoring (RPM), providers can use physiological data to enhance chronic disease management. Covered by Medicare Part B, providers should learn what CPT billing codes are used for RPM in order to optimize care delivery and avoid denied claims.

The Centers for Medicare and Medicaid Services (CMS) has introduced significant changes in the 2025 Physician Fee Schedule Final Rule, marking this as a crucial year for healthcare organizations. These changes are especially important for those already participating in Medicare care management programs or considering participating in them.