Eleven of the group's cardiologists are named on CMS's preliminary CY2027 participant list for the Ambulatory Specialty Model, in the Heart Failure cohort — and today the practice bills no remote physiologic monitoring, chronic care management, principal care management or transitional care management at all. Every reimbursed month built in 2026 improves the position CMS starts grading in 2027. The fee schedule pays for the program; this page sizes it.
Source: the companion CoachCare Value Analysis workbook, MAC locality GA • 10212-01.
This is not a story about a practice that has to be convinced that between-visit data changes cardiac outcomes. The group's own Medicare claims show it already running remote monitoring at scale, on the device side, in heart failure specifically. What is missing is the non-invasive, whole-population layer — and the reimbursement that comes with it.
CPT 93297, 1,098 remote interrogations in CY2024 — roughly five per patient per year — and up 57% from 142 patients in CY2023. These are pulmonary-artery-pressure sensors, a heart-failure device, not a rhythm device. Three of the five physicians billing it are on the CMS preliminary Heart Failure list.
CPT 93296, alongside 628 on remote pacemaker interrogation, 283 on remote ICD interrogation and 47 loop recorders — plus roughly $294K of mobile cardiac telemetry billed by 12 of the group's 21 Medicare-enrolled physicians. A mature, staffed remote-monitoring workflow already exists here.
Full attestation on certified EHR technology, scored through the APM pathway. Promoting Interoperability is one of the four categories the Ambulatory Specialty Model grades — and it is graded at the group level. That category is effectively already solved, which is a credibility asset rather than a gap.
Remote physiologic monitoring, chronic care management, principal care management and transitional care management were queried per-NPI across every physician enrolled under the group's CMS organization identifier, for CY2023 and CY2024. Zero services on every code family, both years.
The hard part of a remote care program is the operating habit, not the technology: a triage inbox, an alert-review protocol, a documented escalation standard, and clinicians who act on data arriving between visits. This practice has run that habit for a decade on the device side. What is missing is the reimbursed layer that extends it from a few hundred implanted patients to the whole heart failure, hypertension, coronary and rhythm panel.
The Ambulatory Specialty Model makes individual specialists personally accountable for heart failure cost and quality. It is not optional, it is scored per physician, and the performance that determines the adjustment starts in calendar 2027.
Eleven of the group's cardiologists are named on the CMS preliminary CY2027 participant list for the Ambulatory Specialty Model, Heart Failure cohort, under the organization Atlanta Heart Associates PC (CMS organization PAC ID 6204737216). Verified bidirectionally by NPI against the CMS Doctors & Clinicians roster — eleven of the twenty-one physicians enrolled under that identifier appear in the file, and the other ten appear nowhere in it under any organization name or state.
CMS states payment adjustments range from −9% to +9% in the first two performance years, increasing to −12% to +12% by the final performance year. Performance year 1 is calendar 2027; that performance lands in payment year 2029. The design is budget-neutral and scored against peers treating the same condition — average performance is the break-even outcome, and there is no opt-out.
Preliminary This is the CY2027 preliminary participant list (dataset modified 2026-02-04, queried 2026-08-03); the final CY2027 list had not yet been published at the query date.
Computed from the same preliminary file: 2,610 Heart Failure cohort NPIs across 944 organizations nationally, and the median participating organization has one named clinician. Only 44 organizations — 4.7% — have eleven or more. Of the 134 Heart Failure cohort NPIs coded to Georgia across 37 organizations, this group ranks third in the state, behind only two health-system-employed cardiology groups.
Read commercially, that is the whole argument in one line: every larger Heart Failure cohort in Georgia sits inside a health system with a population-health department, care-management staff and analytics behind it. This one carries the same scorecard without that infrastructure — and appears to be the largest independent cohort in the state.
New codes 99445 (2–15-day device supply) and 99470 (first 10 minutes of management) make short post-discharge and post-procedure monitoring windows cleanly billable — removing the 16-day floor that previously blocked episodic remote care. That is exactly the window in which post-discharge decompensation is either caught or missed.
This is a named service line with its own owner, P&L and scorecard, not a point solution bolted onto one condition. It follows 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 | In the model? |
|---|---|---|---|---|
| Transitional Care Management | 99495 · 99496 | ~$200 / ~$280 | Every heart failure and post-procedure discharge from the group's admitting hospitals | No — upside |
| RPM setup & device supply | 99453 · 99454 · 99445 (new) | ~$20 setup · ~$52/mo | 99445 unlocks the 2–15-day post-discharge window | Yes |
| RPM treatment management | 99457 · 99458 · 99470 (new) | ~$52 + ~$41 add'l | Monthly review, titration, escalation | Yes |
| Principal Care Management | 99424 · 99425 · 99426 · 99427 | ~$60 + ~$50 add'l | Single high-risk cardiac condition (heart failure) expected to last ≥3 months | Yes |
The value analysis below uses CY2026 rates auto-resolved by MAC carrier and locality for zip 30253 — GA • 10212-01.
The same infrastructure — enrollment, devices, alert triage, escalation, documentation, billing capture — powers each thing the group already cares about.
Every remote care program lives or dies on whether the data lands in the chart the clinicians already use. Here that chart is brand new — and the workflows around it are still being written, which is precisely when a care-management layer is least disruptive to add.
The value analysis on this page does not assume any particular integration depth. No interface cost, timeline or capability is priced into the forecast, and none is claimed here.
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. This group already runs a device inbox; it will have strong, well-earned opinions about alert triage. That is the right conversation to have, and this is the floor it starts from.
Both programs in this service line — remote physiologic monitoring and principal care management — route through the same logic. The engine is program-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 judgment 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 any event can be reconstructed.
Triggered automatically by any emergency-room visit or hospitalization reported in the last 60 days. This is the readmission-prevention spine — and the mechanism behind the 325 hospitalizations avoided in the forecast below. It matters here specifically: four of the five core counties in this footprint exceed both Georgia and national heart-disease mortality, and the model's cost category is framed by CMS around reducing avoidable hospitalizations.
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 program, 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 judgment, 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 scored, risk-bearing CMS model and a serious hospital partnership both actually require.
A 24-month forecast for a two-program service line — remote physiologic monitoring and principal care management — across the group's six offices, 29 referring clinicians, one CoachCare-funded on-site enrollment specialist, and CY2026 rates auto-resolved for MAC locality GA • 10212-01. Transitional care management revenue, specialty-model payment adjustment, avoided-admission savings and procedural throughput are not in these numbers. They are upside on top.
| Line | Year 1 | Year 2 | 24-Month |
|---|---|---|---|
| RPM net reimbursement | $1,198,392 | $3,661,845 | $4,860,237 |
| PCM net reimbursement | $382,321 | $1,197,036 | $1,579,356 |
| Total net reimbursement | $1,580,712 | $4,858,881 | $6,439,593 |
| CoachCare fees | $920,558 | $2,798,958 | $3,719,516 |
| Practice net (after fees) | $660,154 | $2,059,923 | $2,720,077 |
| Practice margin | 41.76% | 42.40% | 42.24% |
| Includes one on-site enrollment 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 −$2,669; 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, device and imaging book, not instead of it.
A continuous clinical picture of the heart failure, hypertension, coronary and rhythm panels between visits — the non-invasive twin of the device data the group already reviews.
Roughly $4.9M of avoided acute cost at an assumed $15K per admission — in a footprint where four of five core counties exceed both state and national heart-disease mortality.
52,701 care-team hours of monitoring, outreach, escalation and documentation carried by the service line rather than by practice staff.
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 exactly — 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 program enrollments; a patient enrolled in both programs counts twice. At month 24 the model's 5,328 enrolled services correspond to 4,360 unique patients once dual enrollment is deduplicated.
CoachCare operates the engine — enrollment 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 enrollment specialist in the model is funded by CoachCare.
Named service-line owner, P&L and scorecard. Confirm the Epic Community Connect integration path with the health system that owns the tenant, and the billing configuration for MAC locality GA • 10212-01. Agree the escalation matrix and discharge criteria. Re-verify the CY2027 specialty-model attribution against the final CMS list, and read the CY2027 Physician Fee Schedule proposed rule before the 2026-09-14 comment deadline.
First, the 223 patients already under implantable hemodynamic monitoring — identified, engaged, and sitting directly on top of the population the specialty model measures. Second, post-discharge patients from the dominant admitting hospital, on the three-touch cadence with short-window RPM placed at discharge.
McDonough, Griffin, East Point, Riverdale, Jackson and Fayetteville enrolling — phased deliberately, because family poverty and uninsured rates differ by a factor of three across the footprint and enrollment yield will follow. Longitudinal RPM and PCM panels running under protocol; monthly scorecard — census, capture rate, revenue per patient-month, escalation volume, readmission signal — reporting to practice governance.
A full performance record on the heart failure panel ahead of the CY2027 performance year — twelve months of documented cost and quality behavior before the clock that determines the 2029 payment adjustment starts running, rather than a program that begins the same month the scoring does.
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 programs on the CoachCare platform.
Programs implemented and operating in market.
Care plan coding and billing that has produced 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 $1,579,356 of the modeled $6,439,593 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 $429,694, RPM accounts for $423,716 and the care-management arm for $5,977.
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.