St. Louis Heart and Vascular billed $414,890 of Medicare remote physiologic monitoring in CY2024 — 9,314 services across eleven of its fifteen physicians — in a programme it started itself in 2021 and that appears nowhere on its own website. New enrolment has fallen 78% in two years, and the care-management layer beside it has never been billed at all. This page sizes what it is worth to restart the engine and attach the arm that is missing.
Source: the companion CoachCare Value Analysis workbook, MAC locality MO • 05302-01.
Most cardiology groups are asked to believe that a remote care programme will work at their practice. This one does not have to. Its own Medicare claims record shows it built one, scaled it group-wide across eleven physicians, and held a management attach rate most vendors would publish as a case study. The question here is not feasibility. It is what stopped — and what it is worth to restart it with the care-management arm attached.
9,314 services across eleven of the group's fifteen physicians in CY2024 Medicare fee-for-service, on CPT 99453 · 99454 · 99457 · 99458. The curve is unambiguous: $0 in CY2019 and CY2020, a $10,009 single-physician pilot in CY2021, $235,392 group-wide in CY2022, a $425,371 peak in CY2023, and $414,890 in CY2024.
Device-setup billing — the cleanest available proxy for new patients entering a programme — fell from 600 setups in CY2022 to 311 in CY2023 to 130 in CY2024, and the number of physicians enrolling anyone at all fell from eleven to five. Managed volume held up because the existing panel persisted, which is why revenue plateaued rather than collapsed. The top of the funnel has closed.
CPT 93294–93298 in CY2024, growing while the physiologic programme stalled. A live July 2026 requisition describes a "Centralized Device Team" reading five named remote platforms, handling missed-transmission follow-up, and holding working knowledge of device billing and coding. Centralised remote-monitoring operations already exist here. The service line extends them; it does not introduce them.
Chronic care management, principal care management, transitional care management, remote therapeutic monitoring and the annual wellness visit are $0 in CY2022, $0 in CY2023 and $0 in CY2024 — every family, every year. Because eleven physicians clear CMS's suppression threshold on the monitoring codes, a care-management programme of comparable scale would be visible in the same file. Verified absent, not suppressed.
The hard part of a remote care programme is not the technology. It is the operating habit — an alert-review protocol, a documented escalation standard, and clinicians who trust data arriving between visits. This practice has run that habit for six years, across two different kinds of remote monitoring. What is missing is enrolment capacity, the documentation engine behind the billable rungs, and a care-management arm that has never existed.
The CY2026 Physician Fee Schedule expanded remote monitoring in ways that map almost exactly onto the two defects visible in this practice's own claims record. Nothing on this page depends on a value-based contract, a shared-savings arrangement or a risk deal. This is fee-schedule revenue, on the Original Medicare base that already exists.
99445 pays the monthly device-supply amount for 2–15 days of data, where 16 or more days were previously required — which had made short post-discharge and post-procedure windows effectively unbillable. That converts two windows this practice generates constantly, the days after a cardiac discharge and the days after a procedure in the group's own ambulatory surgery centre, from unfunded care into billable events.
99470 pays for the first 10 minutes of monthly management time, where the floor had been 20. This matters here specifically: the CY2024 record shows an add-on capture rate of 0.18 — only about eighteen of every hundred managed months captured a second increment of management time — against a device-supply-to-management ratio of 0.91.
In plain terms: when a device is supplied, the practice almost always bills the first block of management time and rarely bills beyond it. That is the signature of a programme that is genuinely staffed but thinly documented — not a device drop. A first-ten-minute code is precisely the instrument that monetises it.
Codes 99424 · 99425 · 99426 · 99427 cover a single high-risk condition expected to last at least three months — and in a cardiology panel the single dominant condition genuinely is the cardiac one. Principal care management stacks with remote monitoring in the same month on the same patient, with discrete time and discrete documentation.
It is $0 today and modeled at $1,304,308 of net reimbursement over 24 months.
A named service line with its own owner, P&L and scorecard, following the Medicare patient from the hospital bed back into the practice and then across the year. Built once, reused for every lever the group already cares about.
| Service | Codes | ~CY2026 Magnitude | Cardiovascular use — and the practice's own record | In the model? |
|---|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every heart failure and post-procedure discharge. Billed $0 in each of CY2022, CY2023 and CY2024 | No — upside |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 opens the 2–15-day window. 99453 is the code whose volume fell 600 → 311 → 130 | Yes |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 · ~$41 add'l · ~$26 | Add-on capture sits at 0.18 today against a 0.91 management attach rate — 99470 monetises the thin rung | Yes |
| Principal Care Management | 99424 · 99425 · 99426 · 99427 | ~$79 / ~$57 · ~$60 + ~$50 add'l | Single high-risk cardiac condition expected to last ≥3 months. $0 in each of the last three published years | Yes |
Magnitudes in this table are national non-facility figures. The value analysis below uses CY2026 rates auto-resolved by MAC carrier and locality for zip 63044 — MO • 05302-01 — not these national figures.
These are Original Medicare fee-schedule codes, and only 43.3% of St. Louis County Medicare beneficiaries sit in Original Medicare. The bi-state footprint adds a wrinkle: the Illinois offices bill under a separate Medicare enrolment and a different Medicaid programme, and the Illinois counties carry materially higher dual-eligible shares — 14.6% in Madison County and 17.7% in St. Clair against 10.9% in St. Louis County. Coinsurance handling, secondary-payer logic and enrolment scripting should be designed per state rather than averaged.
The same infrastructure — enrolment, devices, alert triage, escalation, documentation, billing capture — powers each thing the group already cares about.
Every remote care programme lives or dies on whether the data lands in the chart the clinicians already use. Here the platform is established and roughly a year old — which makes this a favourable moment rather than a reason to wait. What has to be confirmed is not the product. It is who signs off on the interface.
Integration capabilities are CoachCare-provided. The value analysis on this page does not assume any particular integration depth, and no interface cost or timeline is priced into the forecast.
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 practice receives signal, not noise, and never carries surveillance liability it did not agree to. At a group that has run remote alert triage across five device platforms for years, this is a conversation with experts, not an education.
Both programmes in this service line — remote physiologic monitoring and principal care management — route through the same logic. The engine is programme-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 practice's inbox stays clean.
An out-of-range trend is not a judgement 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 the practice can reconstruct any event.
Triggered automatically by any emergency-room visit or hospitalisation reported in the last 60 days. This is the readmission-prevention spine — and the mechanism behind the 245 hospitalizations avoided in the forecast below. It matters here specifically: the practice's principal admitting hospital is rated worse than national on two cardiac excess-days measures — 18.5 more days per 100 discharges for heart failure and 23.1 for heart attack — while its readmission rates sit at the national average.
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 programme, and the practice 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 judgement, 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 with a hospital partner, a payer or an auditor actually requires.
A 24-month forecast for a two-programme service line — remote physiologic monitoring and principal care management — across the group's sites, 23 referring clinicians, one CoachCare-funded on-site enrolment specialist, and CY2026 rates auto-resolved for MAC locality MO • 05302-01. Transitional care management revenue, avoided-admission savings, procedural throughput and any Medicare Advantage or commercial volume are not in these numbers. They are upside on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $949,163 | $2,520,094 | $3,469,257 |
| PCM net reimbursement | $315,458 | $988,849 | $1,304,308 |
| Total net reimbursement | $1,264,622 | $3,508,943 | $4,773,565 |
| CoachCare fees | $736,463 | $2,018,271 | $2,754,733 |
| Practice net (after fees) | $528,159 | $1,490,673 | $2,018,831 |
| Practice margin | 41.76% | 42.48% | 42.29% |
| Includes one on-site enrolment 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 −$552; the first profitable month is month 2. The full model is available as a companion workbook.
Recurring, subscription-like professional-fee volume over 24 months — on top of the existing procedural, imaging and device book, not instead of it. Volume at this scale is exactly why claim generation has to be automated rather than assembled by hand.
A continuous clinical picture of the heart failure, hypertension, coronary disease and atrial fibrillation panels between visits — the physiologic twin of the device data the centralised device team already reviews.
Roughly $3.7M of avoided acute cost at $15K per admission — and direct relief on the cardiac excess-days measure at the practice's principal admitting hospital.
41,590 care-team hours of monitoring, outreach, escalation and documentation carried by the service line rather than by practice staff — none of it on the practice's payroll.
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 — 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 programme enrolments; a patient enrolled in both programmes counts twice. At month 24 the model's 3,537 enrolled services correspond to 2,705 unique patients once dual enrolment is deduplicated.
CoachCare operates the engine — enrolment 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 practice headcount, and the on-site enrolment specialist in the model is funded by CoachCare.
Establish who runs the existing monitoring programme today, under what contract, and what stopped the enrolment — including any notice period or data-portability obligation. Name a physician lead and charter the service line with its own P&L and scorecard. Agree the escalation matrix and discharge criteria alongside the existing device-team protocols. Establish the integration approval path through the management platform's technology function.
Integration built against the NextGen Enterprise build; alert thresholds set by the physician lead; on-site enrolment specialist placed at the Missouri sites; discharge-notification process agreed with the principal admitting hospital. The existing monitored census is assessed and transitioned deliberately rather than displaced on day one — and principal care management is billed for the first time in the practice's history. Month 2 is the first net-positive month in the model.
Hypertension, post-procedure and Illinois-side pathways added with their own coinsurance and onboarding design. The in-scope panel validated against the practice's own chart counts — the highest-leverage single input in the forecast, because the monitoring arm is ceiling-constrained rather than referral-constrained. A second enrolment pathway opened for the principal-care-management arm, which is not.
Monthly scorecard running with enrolments per month and add-on capture at the top of it; excess-days and readmission signal reported; structured monthly reporting live to the largest referring practices and health centres; the transitional-care decision taken on its own merits; Medicare Advantage terms reviewed with the platform's contracting function.
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 programmes day to day.
Successful programme implementations.
Care plan coding and billing generating 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 $1,304,308 of the modeled $4,773,565 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 $305,493, RPM accounts for $300,565 and the care-management arm for $4,927.
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.