The Ecosystem

From Annual Wellness Visits to behavioral health and remote monitoring — with both the software to run each program and a care team to deliver it. Layer the right mix for every patient.

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AWVPreventiveMedicare patients (after 12 months of Part B)

Annual Wellness Visits

The Annual Wellness Visit builds a personalized prevention plan from a health-risk assessment — the natural on-ramp for enrolling patients into the ongoing programs they qualify for.

What it delivers

The anchor visit that surfaces every care opportunity.

APCMPrimary careAll Medicare Part B patients

Advanced Primary Care Management

APCM replaces time-based billing with an activity-based model, letting every Medicare Part B patient receive structured, continuous primary care management without a stopwatch running in the background.

What it delivers

Widest patient eligibility with no time tracking burden.

RPMMonitoringMedicare — acute or chronic condition

Remote Patient Monitoring

RPM streams connected-device readings — blood pressure, glucose, weight, SpO₂ — into the clinical workflow so the team can intervene before a crisis becomes a hospitalization.

What it delivers

Continuous physiologic signals with real-time vital sign alerts.

CCMChronic careMedicare — 2+ chronic conditions

Chronic Care Management

CCM wraps patients with two or more chronic conditions in a comprehensive, 24/7-accessible care plan — the backbone for high-complexity populations that drive the majority of Medicare spend.

What it delivers

Broadest code set and the deepest coordination framework.

RTMMonitoringMedicare — MSK, respiratory, or CBT need

Remote Therapeutic Monitoring

RTM captures non-physiologic therapy data — musculoskeletal, respiratory and cognitive-behavioral — and is uniquely billable by physical, occupational and speech-language therapists.

What it delivers

Extends monitoring revenue to therapy disciplines.

ACPPreventiveMedicare patients — any care setting

Advance Care Planning

Advance Care Planning gives clinicians paid, unhurried time to discuss goals of care and advance directives — often bundled with the Annual Wellness Visit at no cost to the patient.

What it delivers

Meaningful goals-of-care conversations, on the record.

CoCMBehavioral healthMedicare patients with a behavioral health condition

Collaborative Care Management

The Collaborative Care Model integrates a behavioral-health care manager and psychiatric consultant into the practice, using a patient registry and measurement-based treatment to close the mental-health gap.

What it delivers

A psychiatric care team wrapped around primary care.

TCMCare transitionsMedicare — post-discharge from inpatient, observation or SNF

Transition Care Management

TCM covers the fragile 30 days after a hospital, observation or SNF stay. With ADT alerts from the HIE, ZOC surfaces the discharge, prompts the 2-day interactive contact, tracks medication reconciliation and readies the qualifying face-to-face visit — cutting readmissions and capturing 99495/99496 revenue.

What it delivers

Highest-value 30-day service — one billable window per discharge.

At a glance

Compare all eight programs.

Program	Category	Eligibility	Codes	Time	Reimbursement
AWV Annual Wellness Visits	Preventive	Medicare patients (after 12 months of Part B)	G0438G0439	One structured annual visit	$118 – $175 / visit	View
APCM Advanced Primary Care Management	Primary care	All Medicare Part B patients	G0556G0557G0558	None — no time tracking	$16 – $117 / patient	View
RPM Remote Patient Monitoring	Monitoring	Medicare — acute or chronic condition	99453994549945799458	≥ 20 min management time / month	$52 – $144 / patient	View
CCM Chronic Care Management	Chronic care	Medicare — 2+ chronic conditions	9949099439994879948999491	≥ 20 min (standard) · ≥ 60 min (complex)	$66 – $144 / patient	View
RTM Remote Therapeutic Monitoring	Monitoring	Medicare — MSK, respiratory, or CBT need	989759897798976989789898098981	≥ 20 min / month	$77 – $135 / patient	View
ACP Advance Care Planning	Preventive	Medicare patients — any care setting	9949799498	≥ 16 min (first 30-min unit)	$80 – $235 / session	View
CoCM Collaborative Care Management	Behavioral health	Medicare patients with a behavioral health condition	994929949399494G2214	≥ 36–70 min / month (care manager)	$65 – $160 / patient	View
TCM Transition Care Management	Care transitions	Medicare — post-discharge from inpatient, observation or SNF	9949599496	Interactive contact ≤ 2 business days · face-to-face ≤ 7 or 14 days	$204 – $281 / discharge	View

Reimbursement ranges are illustrative and vary by CMS locality and complexity. Our team confirms exact billing for your setting.

Eight programs, engineered to work together.

Annual Wellness Visits

Advanced Primary Care Management

Remote Patient Monitoring

Chronic Care Management

Remote Therapeutic Monitoring

Advance Care Planning

Collaborative Care Management

Transition Care Management

Compare all eight programs.