Custom chronic care management software
We build chronic care management software for provider groups, care management companies and digital health platforms: patient enrollment with consent capture, coordinator worklists, time tracking that knows the 20-minute CCM threshold, comprehensive care plans that write back to the EHR over FHIR, and a monthly billing export for 99490, 99439, 99491, 99487, PCM and the APCM G-codes. The same platform runs RPM alongside CCM without counting a minute twice.
Scope your chronic care management platformFor medical groups, FQHCs, care management companies and health tech teams running Medicare chronic care programs. Updated September 26, 2026.
Eligibility check, initiating visit on file, verbal or written consent recorded
Comprehensive care plan built from EHR problems, medications and goals
Outreach, refills, referrals and after-hours calls logged to the minute
Month-end code selection, claim export and care plan updates sent to the EHR
Illustrative workflow · scope tailored to your environment
The short answer
Chronic care management software runs a Medicare CCM program between office visits. It identifies patients with two or more chronic conditions, records their consent, builds and maintains a comprehensive care plan, gives care managers a worklist for outreach and coordination, tracks clinical staff and practitioner time per calendar month, and at month end selects the right code (99490, 99439, 99491, 99437, 99487, 99489, PCM 99424 to 99427 or APCM G0556 to G0558) and sends a claim-ready record to billing. Good CCM software reads problems, medications and allergies from the EHR and writes the care plan back, so clinicians see one record.
Read our CCM, RPM and RTM billing guide for 2026Start with the real problem
Care managers do the work: they call patients, chase refills, coordinate with specialists and answer after-hours questions. Programs lose money when that work is not documented the way CMS requires. A missing consent note, time logged against the wrong month, the same minutes counted for CCM and RPM, a care plan that was never shared with the patient, or two practices billing CCM for one patient in the same month all turn paid claims into recoupments. We build the software so each of those rules is enforced at the moment the work is recorded, not reconstructed at month end.
What we build
Most programs need several of these. We scope them around the codes you bill and the systems your care team already uses.
Care manager workspaces for patients with two or more chronic conditions, with time rolled up per calendar month and code selection for standard and complex CCM.
CCM, RPM and RTM billing guideDisease-specific care plans for one high-risk condition, such as oncology, nephrology, cardiology or behavioral health, run by the specialist who manages that condition.
Specialty EHR developmentMonthly, non-time-based primary care management with the practice capabilities CMS requires, and rules that stop CCM, PCM or TCM from being billed for the same patient in the same month.
RCM software developmentA FHIR-based care plan service that reads the problem list and medications from the EHR and writes the plan, goals and encounter notes back.
FHIR integration servicesOne patient record and one time ledger for CCM and remote patient monitoring, so device readings feed the care plan and each minute is counted once.
Remote patient monitoring softwareTwo-way messaging, reminders, symptom check-ins and after-hours routing that log each contact to the patient's CCM month automatically.
Patient engagement softwareYour starting point
You have the eligible patients and the care managers but the work lives in spreadsheets and EHR notes. We build the enrollment, care plan, worklist and time ledger around your EHR so the first month bills cleanly.
You run a care management company or a digital health platform that delivers CCM, PCM, APCM and RPM for many practices. We build the multi-tenant platform, per-practice EHR connections and billing exports.
Your current CCM vendor cannot handle APCM, combined RPM and CCM time, or write-back to your EHR. We migrate enrollment, consent and care plan history, then run both systems in parallel for a billing cycle.
The Engineering Engagement
Workstreams are selected around your priorities. Each comes with an output your team can inspect, test and own.
Identify patients with two or more chronic conditions from EHR problem lists and claims history, check that an initiating visit is on file (within one year for CCM), and record verbal or written consent with the cost-sharing explanation and the right to stop at any time.
Build the plan CMS describes: problem list, expected outcome and prognosis, measurable goals, symptom management, planned interventions, medication management, community resources and a review schedule. Give the patient a copy and keep every version.
Timers and manual entries tied to a patient, activity type, staff role and calendar month. The ledger shows progress toward 20, 40 and 60 minutes, separates practitioner time from clinical staff time and refuses to count a minute against two programs.
Route after-hours calls and messages to an on-call clinician who can open the patient's electronic care plan, and record the contact against the patient's month. Assign each patient a designated care team member.
Read problems, medications, allergies and encounters from the EHR, and write the care plan, goals and monthly care management note back. We use FHIR R4 on US Core where the EHR supports writes, and HL7 v2 or CCDA where it does not.
At month end, apply the rules: one practitioner per patient per month, CCM or APCM but not both, PCM for a single condition, complex CCM only with the documented decision making. Export charge-ready lines to your practice management system or clearinghouse.
Enrollment, consent, minutes per patient, codes billed, after-hours contacts and care plan review dates, with every record traceable to the person who created it.
Compare your options
Each option can run a compliant program. The right one depends on how many programs you run and whether care management is your product.
| Custom CCM software | CCM vendor platform | EHR care management module | |
|---|---|---|---|
| Best for | Care management companies, multi-practice groups and products that sell CCM | Single practices that want a program running quickly | Organizations standardized on one EHR with in-house care managers |
| Programs covered | CCM, complex CCM, PCM, APCM, RPM, RTM and BHI on one time ledger | Usually CCM and RPM; APCM support varies by vendor | Depends on the EHR edition and modules licensed |
| EHR connection | Built for your EHRs, with FHIR or HL7 write-back | Vendor's own integrations, often read-only | Native to one EHR, limited across others |
| Billing rules | Rules engine you own and version | Vendor-maintained rules | EHR billing rules and your configuration |
| Data and exit | You own the data model, the code and the patients' history | Export terms set by the vendor contract | Stays in the EHR |
| Cost shape | Build cost, then hosting and support | Per-enrolled-patient or revenue-share fees | EHR module license and configuration |
Many groups start with a vendor and move to a custom platform once they run several programs across more than one EHR.
Expertise is in the decisions
CCM counts clinical staff time in 20-minute blocks, PCM in 30-minute blocks, RPM treatment management in 10 and 20-minute blocks, and APCM is not time based. Keep one ledger per patient per month with the program on each entry, so the same minutes are never billed twice.
CCM needs documented consent before services start and an initiating visit for new patients or those not seen in the past year. APCM needs consent and an initiating visit for patients not seen within three years. Store both as structured data that gates billing.
Only one practitioner can bill CCM for a patient in a month. APCM cannot be billed with CCM, PCM or TCM by the same practitioner in the same month. RPM and BHI can run alongside. Encode these as rules with effective dates, reviewed by your compliance lead.
Decide whether the EHR or the CCM platform is the source of truth for the care plan. We usually keep the working plan in the platform and write a signed version back to the EHR as FHIR CarePlan or a document, with a clear rule for edits made on either side.
Eligibility criteria, care plan templates, escalation thresholds and after-hours protocols are approved by your medical leadership. We build, version and test the approved logic.
The rules engine encodes CMS and payer rules with effective dates and a named approver, and every change is reviewed before it reaches a claim.
Timeline
Dates follow discovery. The number of EHRs, programs and practices sets the schedule more than screen count.
Map enrollment, care plan, time capture and billing for one program with your care managers and billing lead.
Enrollment, consent, care plan, worklists, time ledger and billing export for CCM at one practice.
FHIR or HL7 write-back, then PCM, APCM, RPM and BHI on the same ledger.
More practices, EHRs and tenants, with reporting and audit packs.
Delivered work
Client names are withheld; each is a real engagement. Our open-source FHIR work is public on GitHub.
Patients report pain location, character and its impact on sleep, mood and work; clinicians review weeks of patient-reported outcomes in one view and adjust the plan.
Scheduling, charts, care plans and billing where every record, including the care plan, is a standard FHIR resource on the server.
Clinic visits captured on the device with readings from connected instruments, kept correct offline and reconciled when the network returns.
Wound documentation, eligibility checks and claim scrubbing before submission for a US wound care group, so coding and coverage errors are fixed before the claim leaves.
A headless EHR with a FHIR R4 API and SMART App Launch that passed 47 of 47 ONC (g)(10) SMART App Launch tests in Inferno on 11 June 2026.
From discussion to delivery
Programs, codes, EHRs, care team roles and billing path, agreed in writing.
Care plan templates, worklists and the time ledger reviewed with care managers; billing rules signed off by compliance.
Working software every two weeks, with EHR interface tests against real payloads.
One billing cycle run alongside your current process, reconciled, then cutover and support.
We agree the scope, dependencies, acceptance criteria and commercial model before implementation. Your existing team can stay involved throughout.
Find the right starting point ↗Before you commit
It is the system a practice or care management company uses to run a Medicare CCM program: finding eligible patients, recording consent, maintaining a comprehensive care plan, organizing care manager outreach, tracking time per calendar month and producing the monthly claim. The best CCM software also connects to the EHR so the care plan and notes appear in the patient's chart.
Standard CCM: 99490 (first 20 minutes of clinical staff time) and 99439 (each additional 20 minutes). Practitioner CCM: 99491 (first 30 minutes) and 99437 (each additional 30 minutes). Complex CCM: 99487 (first 60 minutes) and 99489 (each additional 30 minutes). Principal care management: 99424 to 99427. Advanced primary care management: G0556, G0557 and G0558, with G0568, G0569 and G0570 behavioral health add-ons from 2026.
Every activity is logged against a patient, a staff member, a program and a calendar month, with a timer or a manual entry and a note. The ledger shows progress toward 20, 40 and 60 minutes, separates clinical staff time from practitioner time, and locks at month end so time cannot move between months after billing.
Yes. Medicare allows remote patient monitoring alongside CCM or PCM in the same month, as long as each minute of care management counts toward one service only. Our platforms keep one time ledger with the program on every entry, so the billing export cannot double count.
Advanced primary care management (G0556, G0557 and G0558) started on 1 January 2025. It is billed monthly without a time threshold when the practice provides a defined set of primary care capabilities, and the level depends on the number of chronic conditions and Qualified Medicare Beneficiary status. APCM cannot be billed with CCM, PCM or TCM by the same practitioner in the same month.
Before CCM starts, the patient gives verbal or written consent after being told about the service, cost sharing, that only one practitioner can bill it per month and that they can stop at any time. We store consent as a structured record with the date, method, staff member and script version, and billing is blocked without it.
CCM requires that patients can reach a clinician at any hour for urgent needs, and that the person answering can see the electronic care plan. We build on-call routing, mobile access to the care plan and a logged record of each after-hours contact.
It reads the problem list, medications, allergies and encounters, and writes the care plan, goals and monthly care management note back. With FHIR R4 we use CarePlan, Goal, Condition, MedicationStatement, Encounter and DocumentReference on US Core; with older EHRs we use HL7 v2 or CCDA. We scope write-back per EHR because vendors expose different write APIs.
Buy when you run one program at one practice and a vendor supports your EHR. Build when care management is your product, when you run CCM, PCM, APCM and RPM across several practices or EHRs, or when a vendor's per-patient fees and data terms no longer fit. A custom platform gives you one time ledger, your own rules engine and ownership of the data.
Cost depends on the number of programs (CCM, PCM, APCM, RPM), the EHRs you need to read from and write to, whether the platform is multi-tenant, and the billing path. We give a fixed-scope estimate after discovery, broken down by module and interface, so you can phase the build.
A first program at one practice, with enrollment, consent, care plans, worklists, time tracking and billing export, is planned in months, not years. EHR write-back and additional programs follow in phases. EHR vendor access and app review can set the pace, so we start them at kickoff.
Yes. We build the HIPAA Security Rule safeguards into the product: role-based access, audit logs of every view and change, encryption in transit and at rest, and BAA-covered hosting. We sign BAAs and we are ISO 27001:2022 certified.
A useful first conversation
Tell us what exists today, who uses it and where the workflow breaks. We’ll discuss the scope, access dependencies and the next practical step.
A product overview and a de-identified workflow are enough to start. No patient records or credentials are needed.
These are independent reference sources, not endorsements. Applicability, platform access and current requirements are confirmed for your project.
