Know which patients need attention, before the next visit.

Chronic Care Management (CCM) is a Medicare service for ongoing care coordination, mostly outside office visits, for patients with two or more chronic conditions expected to last at least 12 months or until death that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. It requires patient consent and a comprehensive care plan, and CCM services are billed monthly based on time.

Arxova shows a practice's consented patients ordered by open alerts and missing data, charts trends between visits, and holds care-plan recommendations and staff tasks. Staff log care-management time with a timer, sign encounter notes that export as a PDF and a FHIR DocumentReference, and export a monthly summary of minutes per patient. The practice decides what any of it means for a claim.

Advanced Primary Care Management (APCM) is a set of Medicare codes, introduced for 2025, that pay monthly for comprehensive primary care management without the time thresholds used by CCM. Payment is tiered by patient complexity, and the practice must be able to provide defined services such as round-the-clock access, continuity of care, care management, care transitions and population-level follow-up.

CCM is time-based and limited to patients with two or more qualifying chronic conditions. APCM is billed monthly without minimum minutes, can apply to any patient for whom the practice provides primary care, and depends on the practice offering a defined set of capabilities. CMS restricts billing overlapping care-management services for the same patient and period, so practices should check current CMS rules.

Transitional Care Management (TCM) covers the 30 days beginning on the day a patient is discharged from an inpatient hospital, skilled nursing facility or certain other settings to their home or community. It requires an interactive contact within two business days of discharge, a face-to-face visit within 7 or 14 days depending on complexity, and medication reconciliation no later than that visit.

Principal Care Management (PCM) is care management focused on a single high-risk condition, expected to last at least three months, that places the patient at significant risk of hospitalization, acute exacerbation, functional decline or death. It is common in specialty practices and is billed monthly based on time.

General Behavioral Health Integration (BHI) is care management for behavioral health conditions delivered within a medical practice, including assessment, care planning and ongoing follow-up, under the direction of a treating practitioner and billed monthly based on staff time.

The Psychiatric Collaborative Care Model (CoCM) is a specific team-based model in which a treating practitioner, a behavioral health care manager and a psychiatric consultant work together using a patient registry and measurement-based care. It has its own staffing and billing requirements, separate from general BHI. Arxova does not fulfil CoCM requirements.

Remote Physiologic Monitoring (RPM), often called remote patient monitoring, is the collection and review of physiologic data such as blood pressure, weight or glucose from a patient outside the clinic. For Medicare, the device must meet the FDA definition of a medical device, data must be transmitted automatically, and billing depends on how many days of data are collected and how much time is spent on management.

Not automatically. Medicare RPM requires a device that meets the FDA definition of a medical device, automatic data transmission, medical necessity and other CPT and payer requirements. Consumer wearable data can be useful clinical context, but it does not automatically qualify as billable RPM. Practices should confirm device eligibility before billing.

RPM tracks physiologic data, such as blood pressure or weight. Remote Therapeutic Monitoring (RTM) tracks non-physiologic data, such as therapy adherence, therapy response, and musculoskeletal or respiratory status, and can include patient-reported data. RTM is commonly used by physical and occupational therapists. Both have their own device and billing requirements.

No. Arxova provides health-data, care-management and workflow infrastructure. It does not determine Medicare or payer eligibility, does not submit claims, and does not guarantee reimbursement. The practice is responsible for eligibility, documentation, coding and billing.

Yes. Arxova includes change-from-baseline alerts for heart failure and peripheral artery disease, and a walking view built for vascular and rehabilitation care. Any specialty can use the panel, care plans, tasks, time logging and signed notes.

Patients connect their medical records from more than 25,000 hospitals and health institutions, along with Apple Health, Android Health Connect, wearables and connected scales, in the Arxova app. They then grant a practice access to specific types of data. The provider console shows only what that grant covers.

Provider access is patient-level and exists only because an individual patient granted it to a practice for their care. The patient chooses which types of data the practice can see and can revoke access. Aggregate dashboards of the kind employers or universities use summarize groups and should never expose an individual's record. Arxova's provider console is not an aggregate dashboard.