athenahealth RPM & CCM Integration Guide 2026

The Dual-EHR Reality

In post-acute and senior living care, two separate EHR systems operate in parallel. The facility — whether it is a skilled nursing facility, assisted living community, or memory care unit — runs its own EHR for day-to-day clinical operations: charting, medication administration, ADT tracking, and care planning. PointClickCare, ALIS, MatrixCare, and August Health are the dominant platforms in this space.

But the ordering physician who prescribes RPM, CCM, and other Medicare programs typically works out of an ambulatory practice. That physician documents in a completely separate EHR — often athenahealth. The physician's chart is where billing happens. Medicare claims for RPM (99453-99458), CCM (99490-99491), and other care management programs must be submitted by the ordering physician through their practice EHR, not through the facility system.

This creates a persistent data gap. Monitoring devices capture vital signs at the facility. Nursing staff need those readings in the facility EHR for clinical workflows. But billing documentation needs to reach athenahealth for claims submission. Without a bridge between both systems, someone is manually transferring data — printing reports, re-keying readings, or emailing PDFs. That manual process introduces transcription errors, delays claims submission, and consumes clinical staff time.

CCN Health eliminates this gap by integrating with both systems simultaneously. The facility EHR receives clinical monitoring data for nursing workflows. athenahealth receives CPT-ready billing documentation for claims submission. No manual data transfer between systems.

---

How CCN Health Bridges athenahealth + Facility EHRs

CCN Health connects to athenahealth through a certified Marketplace API integration using FHIR R4 and proprietary APIs. Simultaneously, it connects to the facility EHR through that system's native API. This dual-connection architecture means data flows to the right system automatically based on its purpose.

Data Flow Architecture

Data Type	Direction	From / To
Patient demographics	Facility EHR to CCN Health	Census and ADT sync on admission
Patient conditions and medications	athenahealth to CCN Health	Problem list, active prescriptions
Vital sign readings	Devices to CCN Health to both EHRs	Automated posting to facility charts and athenahealth observations
Clinical alerts	CCN Health to both EHRs	Threshold-based notifications for nursing and physician teams
Care plans	Bi-directional	Synced across systems to keep monitoring protocols aligned
Billing documentation	CCN Health to athenahealth	CPT-ready records for claims submission

How It Works in Practice

When a patient is enrolled in RPM at a facility, CCN Health pulls demographic data from the facility EHR (census sync) and clinical context from athenahealth (problem list, medications, existing care plans). Monitoring protocols are configured based on the combined clinical picture.

As the patient uses their monitoring device — blood pressure cuff, weight scale, glucose meter, pulse oximeter, or contactless sensor — readings transmit to CCN Health. From there, two things happen simultaneously:

1. Vital signs post to the facility EHR so nursing staff see current readings in their normal workflow without logging into a separate system
2. Clinical documentation and billing records route to athenahealth so the ordering physician has CPT-ready records for Medicare claims submission

This dual-posting happens automatically. No staff member copies data between systems.

athenahealth Marketplace Integration

CCN Health's athenahealth integration is certified on the athenahealth Marketplace — meaning it meets athenahealth's security, interoperability, and data integrity standards. The integration uses:

• FHIR R4 clinical observation posting for vital signs and monitoring data
• Proprietary APIs for patient matching, automated demographic sync, and revenue cycle integration
• CCDA document exchange for structured clinical documentation
• Real-time data feeds that keep patient records current without batch processing delays

The Marketplace certification ensures the integration is vendor-supported and maintained through athenahealth platform updates — not a fragile custom connection that breaks when either system upgrades.

---

Facility EHR Pairings

CCN Health bridges athenahealth with all four supported facility EHRs. Each pairing creates a complete dual-EHR workflow tailored to the facility type and care setting.

athenahealth + PointClickCare

PointClickCare is the dominant EHR in skilled nursing facilities and many senior living communities. The CCN Health integration connects athenahealth and PointClickCare through direct APIs on both sides:

• Connection: Direct API with bi-directional sync between both systems and CCN Health
• Data sync: Real-time vital sign posting to PCC resident charts, ADT event monitoring, census sync, and care plan data flowing to CCN Health for protocol configuration
• Billing flow: CPT-ready documentation routes from CCN Health to athenahealth for the ordering physician to submit claims
• Care settings: Skilled nursing facilities, long-term care, CCRCs, and senior living communities running PointClickCare

This pairing is the most common dual-EHR configuration. The facility's nursing team works entirely within PointClickCare while the physician practice manages billing through athenahealth — with CCN Health ensuring data reaches both systems automatically.

View all PointClickCare integration guides

athenahealth + ALIS

ALIS is built specifically for senior living operators — assisted living, independent living, and memory care communities. The ALIS integration with CCN Health provides:

• Connection: API integration with automated data exchange
• Data sync: Automated vital sign charting in ALIS resident records, resident demographic sync, and alert notifications within ALIS workflows
• Billing flow: All billing documentation routes to athenahealth — ALIS handles clinical data flow only
• Care settings: Assisted living, independent living, senior living communities, and memory care units running ALIS

Because ALIS is purpose-built for senior living rather than skilled nursing, the clinical workflows differ from PointClickCare. CCN Health adapts its data posting to match ALIS's resident record structure while maintaining the same athenahealth billing documentation flow.

View all ALIS integration guides

athenahealth + MatrixCare

MatrixCare serves post-acute care and senior living organizations with deep support for MDS documentation and PDPM-aligned workflows. The CCN Health integration connects athenahealth with MatrixCare through:

• Connection: API integration with automated vitals flow and documentation sync
• Data sync: MDS documentation context, automated vital sign posting, PDPM-aligned billing documentation, and care transition management between care levels
• Billing flow: CPT-ready records route to athenahealth for physician billing — MatrixCare's PDPM alignment supports facility-side documentation without duplicating the billing workflow
• Care settings: Post-acute care, skilled nursing, senior living, and organizations managing transitions between care levels

MatrixCare's MDS and PDPM capabilities are complementary to CCN Health's RPM/CCM documentation. Monitoring data can inform MDS assessments while billing for care management programs flows separately through athenahealth.

View all MatrixCare integration guides

athenahealth + August Health

August Health is a modern EHR designed for assisted living and memory care communities. The CCN Health integration bridges athenahealth with August Health through:

• Connection: API integration with resident record sync
• Data sync: Resident demographic and clinical record sync, medication management data, vital sign posting, and family communication portal compatibility
• Billing flow: All Medicare billing documentation routes to athenahealth — August Health handles facility-side clinical documentation and family communication
• Care settings: Assisted living, memory care, and senior living communities using August Health

August Health's family communication portal is a distinctive feature — families can see resident health information shared by the community. CCN Health's monitoring data, when posted to August Health, becomes part of the clinical picture available through those family-facing channels while billing documentation flows separately to athenahealth.

View all August Health integration guides

---

Supported Medicare Programs

CCN Health supports all five Medicare care management programs through the athenahealth integration. Each program has its own CPT codes, clinical requirements, and billing documentation — all generated automatically and routed to athenahealth for claims submission.

RPM (Remote Patient Monitoring)

CPT Code	Description	2026 Rate
99453	Initial device setup and patient education	$21.71 (one-time)
99454	Device supply, 16+ days of readings per 30-day period	$52.11/month
99457	First 20 minutes of clinical monitoring time	$51.77/month
99458	Each additional 20 minutes of monitoring time	$41.42/month
99091	Physician interpretation and review of data	$58.48/month

CCM (Chronic Care Management)

CPT Code	Description	2026 Rate
99490	First 20 minutes of clinical staff time	~$62/month
99491	First 30 minutes of physician/QHP time	~$86/month
99439	Each additional 20 minutes of staff time	~$47/month

PCM (Principal Care Management)

CPT Code	Description	2026 Rate
99424	First 30 minutes of physician/QHP time	~$88/month
99425	Each additional 30 minutes of physician/QHP time	~$61/month
99426	First 30 minutes of clinical staff time	~$68/month
99427	Each additional 30 minutes of staff time	~$54/month

BHI (Behavioral Health Integration)

CPT Code	Description	2026 Rate
99484	Care manager time, 20+ minutes	~$53/month
99492	Psychiatric collaborative care, initial month	~$145
99493	Psychiatric collaborative care, subsequent months	~$130/month

RTM (Remote Therapeutic Monitoring)

CPT Code	Description	2026 Rate
98975	Initial device/software setup	~$19 (one-time)
98976	Device supply for respiratory system	~$50/month
98977	Device supply for musculoskeletal system	~$50/month
98980	First 20 minutes of treatment management	~$48/month
98981	Each additional 20 minutes	~$38/month

All five programs generate separate billing documentation streams. A single patient enrolled in RPM and CCM simultaneously receives two distinct sets of CPT-ready records in athenahealth — one for each program — with proper time tracking and clinical documentation to support each claim independently.

---

Billing & Reimbursement

The Billing Entity Rule

In a dual-EHR setup, billing responsibility is straightforward: the ordering physician practice submits all Medicare claims through athenahealth. The facility EHR — PointClickCare, ALIS, MatrixCare, or August Health — handles clinical documentation and day-to-day care workflows but does not submit care management billing.

Role	System	Responsibility
Facility nursing staff	PointClickCare, ALIS, MatrixCare, or August Health	Clinical monitoring, care plans, medication administration, daily charting
Ordering physician practice	athenahealth	Medicare claims submission for RPM, CCM, PCM, BHI, RTM
CCN Health	Monitoring platform	Device management, clinical monitoring, automated billing documentation routed to athenahealth

CCN Health generates CPT-ready billing records — including time logs, clinical documentation, and device compliance data — and routes them directly to athenahealth through the Marketplace API. The physician practice reviews and submits claims through athenahealth's revenue cycle management tools without manual documentation assembly.

What "CPT-Ready" Means

Each billing record routed to athenahealth includes:

• CPT code identification with the specific codes supported by the patient's enrollment
• Time tracking documentation showing minutes of clinical monitoring activity per program
• Device compliance data confirming 16+ days of readings for RPM device codes (99454)
• Clinical notes summarizing monitoring activity, alerts, interventions, and care coordination
• Patient consent records confirming enrollment authorization

This documentation is structured to support claims submission directly from athenahealth — reducing the back-and-forth between clinical and billing teams.

---

Revenue Stacking Examples

Medicare allows concurrent enrollment across multiple care management programs for patients who meet clinical criteria. CCN Health tracks time and documentation separately for each program, generating independent billing streams routed to athenahealth.

Scenario 1: RPM Only

A patient with hypertension monitored via blood pressure cuff, meeting 16+ days of device readings and 20 minutes of clinical monitoring time per month.

Code	Description	Monthly
99454	Device supply (16+ days)	$52.11
99457	First 20 minutes clinical time	$51.77
	Monthly total	$103.88

Scenario 2: RPM + CCM

The same patient also has diabetes and COPD, qualifying for CCM (two or more chronic conditions requiring a comprehensive care plan).

Code	Description	Monthly
99454	RPM device supply	$52.11
99457	RPM clinical time (20 min)	$51.77
99490	CCM staff time (20 min)	~$62.00
	Monthly total	~$165.88

Scenario 3: RPM Full Stack + CCM Extended

A complex patient qualifying for full RPM code stacking (including physician interpretation and additional clinical time) plus extended CCM.

Code	Description	Monthly
99454	RPM device supply	$52.11
99457	RPM clinical time (20 min)	$51.77
99458	RPM additional time (20 min)	$41.42
99091	Physician interpretation	$58.48
99490	CCM staff time (20 min)	~$62.00
	Monthly total	~$265.78

Adding 99091 physician interpretation requires documented review of monitoring data by the physician — distinct from the clinical monitoring time captured under 99457/99458. The athenahealth integration supports this by routing device data summaries and trend reports to the physician's chart for documented review.

These revenue scenarios represent per-patient monthly reimbursement. For a practice managing 50 patients on RPM + CCM, the estimated monthly revenue from care management programs alone would be approximately $8,294 per month (50 patients at $165.88 each).

---

Getting Started

Deploying the athenahealth dual-EHR integration through CCN Health follows a structured process:

Step 1: Integration Assessment. The CCN Health team evaluates the practice's athenahealth configuration and the facility EHR(s) in use. This determines the specific API connections needed and any workflow customization required for the practice's clinical environment.

Step 2: API Connection and Patient Matching. CCN Health establishes the Marketplace API connection with athenahealth and the facility EHR API connection simultaneously. Automated patient matching ensures records are linked correctly across both systems without manual reconciliation.

Step 3: Clinical Workflow Configuration. Monitoring protocols, alert thresholds, escalation paths, and documentation templates are configured based on the practice's clinical preferences. Billing documentation routing is tested to confirm CPT-ready records appear correctly in athenahealth.

Step 4: Enrollment and Go-Live. Patients are enrolled in qualifying programs with device assignment and consent documentation. Device readings begin flowing to both EHRs immediately, and billing documentation routes to athenahealth from the first monitoring period.

Because the athenahealth integration is Marketplace-certified and pre-built, the technical setup is measured in days rather than the weeks required for custom integrations. The CCN Health team handles the entire integration process — the practice does not need dedicated IT resources or development work.

Browse all athenahealth integration guides | Schedule a consultation

---

Disclaimer: This article is for informational purposes only and does not constitute medical, legal, or billing advice. CPT code reimbursement amounts are estimates based on CMS published fee schedules and may vary by region, payer, and clinical circumstances. Always consult qualified healthcare, billing, and technology professionals for guidance specific to your practice.