Chronic care management support
Turn Monthly Care-Management Requirements Into a Coordinated Workflow
Kitronixe helps practices organize the operational and billing workflows surrounding chronic care management programs - from patient identification and enrollment tracking through care-plan workflow visibility, documented activity, billing readiness and reporting - within the agreed scope of service.
Day 1Day 20 of the monthly cycleDay 30
- Candidates for Review64
- Enrollment Pending18
- Consent / Enrollment Workflow11
- Care Plan Workflow23
- Monthly Activity142
- Documentation Review27
- Billing Readiness96
- Follow-Up Required9
Illustrative data for a fictional practice’s program. Not a Kitronixe result, and not a statement that any record is eligible or billable.
Clinical responsibility: Clinical decisions, care planning and clinical services remain the responsibility of appropriately qualified healthcare professionals unless specifically included in an approved clinical-services agreement.
Every month, again
A program that repeats monthly needs a workflow that does too
A chronic care management program repeats every month. Each cycle has its own administrative work - who is enrolled, whether consent is on file, whether the care-plan workflow is current, what activity was documented, and what is ready for billing review - and it has to be done again the next month.
Kitronixe supports that operational side: tracking, administration, documentation workflow, billing readiness and reporting, depending on current program, payer and patient requirements. The care itself - assessment, care planning and clinical decisions - stays with the practice’s qualified clinicians.
The monthly CCM cycle
Ten stages, then the month begins again
Each month
Patient Identification / Review
Stage 1 of 10
Patient Identification / Review
Patients the practice may consider for the program are organized for clinical review.
- 01
Patient Identification / Review
Patients the practice may consider for the program are organized for clinical review.
- 02
Program Eligibility Review
Program and payer requirements checked for each patient, where applicable.
- 03
Consent / Enrollment Workflow
Consent and enrollment tracked to completion and recorded.
- 04
Care-Plan Workflow
The care-plan workflow tracked; the plan is created and approved by the clinical team.
- 05
Monthly Care Coordination Activity
The month’s coordination activity carried out by the practice team and tracked.
- 06
Documentation
Activity documented in the practice’s systems, as the program requires.
- 07
Activity / Requirement Review
The month’s documented activity reviewed against program requirements.
- 08
Billing Readiness
A workflow readiness review before billing - not a guarantee of payment.
- 09
Reporting
Program status, activity and outstanding work reported to the practice.
- 10
Next Monthly Cycle
Open items carried forward and the next month’s cycle begins.
A workflow cycle, not coding guidance: what applies each month depends on current program, payer and patient requirements.
Who does what
Clinical care stays clinical. The workflow around it is shared.
Practice / provider
Clinical responsibility
- Clinical decision-making
- Clinical assessment
- Care-plan approval
- Medical treatment
- Clinical escalation
Shared workflow
Coordinated between both
- Patient status visibility
- Outstanding tasks
- Follow-up workflow
- Program reporting
Kitronixe support
Operational support
- Workflow tracking
- Enrollment administration where scoped
- Documentation workflow support
- Activity tracking
- Billing workflow
- Reporting
Clinical responsibility: Clinical decisions, care planning and clinical services remain the responsibility of appropriately qualified healthcare professionals unless specifically included in an approved clinical-services agreement.
Chronic Care Management
CCM Revenue Opportunity Calculator
Estimate potential gross reimbursement opportunity for a Chronic Care Management population using your patient mix, expected participation, service utilization and reimbursement assumptions.
- Patient population
- Participation
- Program assumptions
- Revenue opportunity
Patient population
Aggregate counts only - never a name, an ID or a diagnosis.
Total Medicare / Medicare Advantage population0
Participation
How many of the review population enroll, and how many take part in a given month.
ScenarioPlanning assumption
Sets the three participation assumptions. Every value stays editable, and no scenario changes an allowed amount.
- Potential review population
- 0
- Estimated enrolled participants
- 0
- Estimated monthly participating
- 0
Program and reimbursement assumptions
A simple estimate uses one average monthly amount per participating patient. Advanced assumptions model the configured service components, each with its own utilization and amount.
Your estimated opportunity
Gross reimbursement opportunity - before any cost, never a guarantee.
Combined monthly gross opportunity
$0
Combined annual gross opportunity
$0
Monthly participating patients
0
Avg. monthly amount per participant
$0
- Potential review population0
- Estimated enrolled participants0
- Original Medicare monthly opportunity$0
- Medicare Advantage monthly opportunity$0
- Avg. annual amount per participant$0
Estimated combined monthly gross opportunity $0, annual $0, for 0 monthly participating patients.
- Active Medicare / MA population0
- Potential program review population0
- Estimated enrolled participants0
- Estimated monthly participating0
- Original Medicare$0
- Medicare Advantage$0
- Monthly gross opportunity$0
- Annual gross opportunity$0
Reimbursement assumptionsCMS-derived
- Medicare rate basis
- Not configured - the estimate uses the allowed amounts you enter
- Locality
- Default planning amount where configured, otherwise visitor-entered
- Effective year
- 2026
- Last reviewed
- 2026-09-26
Original Medicare amounts vary by year, locality, service and setting. Medicare Advantage payment and coverage vary by plan, contract and program rules, and are never assumed equal to Original Medicare.
The program work queue
Every program record, with its status and next step
CCM program work queue
Filter by status, provider, location or month
Record 01Review Candidate
Provider A · Location 1 · Month 2
Provider review
Record 02Enrollment Pending
Provider B · Location 1 · Month 2
Enrollment outreach
Record 03Consent Workflow
Provider A · Location 2 · Month 2
Record consent
Record 04Care Plan Pending
Provider C · Location 2 · Month 2
Awaiting clinical team
Record 05Monthly Activity
Provider B · Location 1 · Month 2
Track this month’s activity
Record 06Documentation Review
Provider A · Location 1 · Month 1
Confirm documentation
Record 07Billing Review
Provider C · Location 2 · Month 1
Readiness review
Record 08Follow-Up Required
Provider B · Location 2 · Month 1
Resolve open item
Record 09Monthly Activity
Provider C · Location 1 · Month 2
Track this month’s activity
Record 10Billing Review
Provider A · Location 2 · Month 1
Readiness review
10 records shown
Illustrative queue: invented program records, identified by number, with providers as letters. No patient or clinical information; not a Kitronixe result.
Monthly readiness check
Reviewed before billing, every month
Workflow readiness review - Record 07, Month 1
Mark an area ready or open
5/7
Workflow review not complete
2 areas are still open.
A workflow readiness review - not legal or coding compliance certification, and not a guarantee of reimbursement.
What is supported
CCM workflow support, within the agreed scope
Identification & enrollment
Patient identification workflow
Patients the practice may want to review for the program, organized for clinical review - the practice decides.
Program eligibility workflow
Program and payer requirements tracked for each patient under review, where applicable.
Enrollment / consent tracking
Enrollment and consent status tracked, with outstanding items followed up.
The monthly workflow
Care-plan workflow support
Whether each care plan is in place and current is tracked; the plan itself is the clinician’s.
Monthly task tracking
Each month’s program tasks listed, assigned and followed through.
Care coordination workflow visibility
Coordination activity visible across the team, so nothing waits unseen.
Documentation support
Documentation workflow tracked so required information is available for review.
Exception follow-up
Missing items, stalled enrollments and open tasks followed up.
Ongoing monthly workflow
The cycle restarted each month without rebuilding it from scratch.
Billing
Billing readiness
A workflow readiness review before billing - subject to documentation and coverage requirements.
Claim workflow support
CCM claims worked through submission and follow-up, where it is part of the scope.
Reporting & visibility
Program reporting
Program census, enrollment, monthly activity and outstanding work, reported regularly.
Provider visibility
Program status by provider and location, so each provider sees their own panel.
Reporting
Program status, by provider and location
- Program Census
- Enrollment Status
- Care-Plan Workflow
- Monthly Activity Status
- Documentation Outstanding
- Billing Readiness
- Follow-Up Required
- Provider / Location View
Where this sits
CCM support, RPM support and Physician Billing
Chronic Care Management SupportThis page
The monthly operational and billing workflow around a CCM program.
Remote Patient Monitoring Support
The same kind of support for eligible RPM programs and device workflow.
Physician Billing
Professional-fee billing for the providers, across all their services.
Why Kitronixe
How Kitronixe supports a CCM program
Clear clinical boundaries
Operational support is kept separate from clinical care, and the page and the engagement say so.
A cycle, not a scramble
The monthly work is organized as a repeating workflow rather than rebuilt at month end.
Documentation workflow support
What the program needs documented is tracked, so gaps are found before billing review.
Billing readiness, reviewed
Readiness is reviewed against current requirements - never assumed.
Provider-level visibility
Each provider and location sees their program status and outstanding tasks.
Fits with RCM and RPM
CCM support can sit alongside remote patient monitoring support or full RCM.
What does Kitronixe support for CCM?
The operational and billing workflow around a chronic care management program: patient review lists, enrollment and consent tracking, care-plan workflow status, monthly activity tracking, documentation workflow, billing readiness and program reporting, within the agreed scope.
Does Kitronixe provide the clinical care?
No. Clinical decisions, care planning and clinical services remain the responsibility of appropriately qualified healthcare professionals, unless specifically included in an approved clinical-services agreement. Kitronixe supports the workflow around that care.
Can you help identify patients for program review?
Yes - by organizing patients the practice may want to consider into a review list. Whether a patient is appropriate for the program is a clinical decision made by the practice, depending on current program, payer and patient requirements.
Can you track enrollment and consent workflows?
Yes. Enrollment and consent status is tracked for each patient, with outstanding items followed up and recorded.
Can you support care-plan workflow tracking?
Yes. Kitronixe tracks whether each care plan is in place, current and awaiting action. Creating and approving the care plan remains with the clinical team.
Can you help track monthly activity?
Yes. Each month’s program activity is tracked against the program’s requirements, so the practice can see what is documented and what is still outstanding.
Can you support CCM billing workflows?
Yes, where billing is in scope: a workflow readiness review, claim submission and follow-up. Whether a month is billable depends on documentation, program and coverage requirements; readiness review is not a guarantee of reimbursement.
Can you provide program reporting?
Yes: program census, enrollment status, care-plan workflow, monthly activity status, documentation outstanding, billing readiness and follow-up required, by provider and location.
Can CCM support work across multiple providers?
Yes. The program can be tracked by provider and location, with each provider’s panel and outstanding tasks reported separately.
Can CCM support be combined with RCM services?
Yes. CCM support can stand alone, sit alongside remote patient monitoring support, or be part of a wider revenue cycle management engagement.
Talk through your CCM workflow
Tell us how the program runs month to month today. We will say plainly which parts of the workflow we could support.