Charm Health RPM & CCM Integration Guide 2026

The Dual-EHR Reality for Independent Practices

Independent physicians and small group practices face a structural challenge that larger health systems never encounter. The practice runs on one EHR — in this case, Charm Health — but many of their chronically ill patients reside in senior care facilities that run on an entirely different system. A cardiologist managing hypertensive patients in a skilled nursing facility does not have access to PointClickCare. An internist overseeing COPD patients in assisted living cannot log into ALIS. The physician's clinical record lives in Charm Health; the patient's day-to-day care record lives in the facility EHR.

This gap becomes a serious operational problem when adding Medicare care management programs. RPM requires continuous device data. CCM requires documented care coordination. PCM, BHI, and RTM each require time-tracked clinical activities tied to the patient record. If the physician cannot see what is happening in the facility — and the facility cannot see what the physician is ordering — both sides operate with incomplete information. Manual workarounds emerge: faxed vital sign logs, phone calls for status updates, duplicated documentation that no one trusts.

Charm Health is built for exactly this practice profile. It is a cloud-based EHR with strong patient portal capabilities, automated progress note generation, telehealth scheduling, and medication reconciliation — all features that independent and small group practices rely on daily. What it is not built for is pulling real-time clinical data from a facility EHR that the practice does not control.

CCN Health solves this by integrating with both sides simultaneously. The Charm Health REST API connection handles billing documentation, progress notes, and patient engagement. The facility EHR connection — whether PointClickCare, ALIS, MatrixCare, or August Health — handles clinical data flow within the care setting. The physician practice never needs to log into the facility system. The facility never needs to change its workflows.

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How CCN Health Bridges Charm Health and Facility EHRs

Architecture Overview

CCN Health sits between the practice EHR and the facility EHR, functioning as a clinical data bridge with monitoring intelligence layered on top. The integration is not a simple pass-through. CCN Health ingests patient data from the facility, applies monitoring protocols and alert logic, captures time-tracked clinical activities, and generates program-specific documentation that routes to the correct system.

The Charm Health side uses a REST API integration for clinical data exchange and patient engagement workflows. The facility side uses the integration method native to each facility EHR — direct API for PointClickCare, API integration for ALIS, MatrixCare, and August Health.

Data Flow Architecture

Data Type	Source	Destination	Purpose
Patient demographics	Facility EHR	CCN Health	Enrollment, identity matching
Vital sign readings	RPM devices	Facility EHR + Charm Health	Clinical charting in both systems
ADT events	Facility EHR	CCN Health	Protocol adjustments on admission/discharge/transfer
Census updates	Facility EHR	CCN Health	Active patient roster sync
Progress notes	CCN Health	Charm Health	Automated clinical documentation
Billing documentation	CCN Health	Charm Health	CPT-ready records for claims submission
Care plan updates	Facility EHR	CCN Health	Monitoring threshold adjustments
Patient portal content	CCN Health	Charm Health	Patient engagement through Charm portal
Medication lists	Facility EHR	CCN Health	Context for clinical alerts and reconciliation

How Data Moves in a Typical Workflow

A patient in a skilled nursing facility has their blood pressure taken by an RPM device. The reading transmits to CCN Health, where it is evaluated against the patient's clinical thresholds. The vital sign is posted to the facility EHR (PointClickCare, ALIS, or whichever system the facility uses) so nursing staff can see it in their normal workflow. Simultaneously, the reading is documented in a progress note that flows to Charm Health, where the ordering physician can review it alongside the patient's full clinical history. If the reading triggers an alert, both the facility care team and the physician practice are notified. At the end of the billing period, CPT-ready documentation reflecting all monitored readings, time-tracked activities, and clinical interventions routes to Charm Health for claims submission.

No manual data entry at any step.

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Facility EHR Pairings

CCN Health bridges Charm Health with four facility EHR platforms. Each pairing is purpose-built for the facility EHR's data model and clinical workflows.

PointClickCare

Connection method: Direct API with bi-directional sync

PointClickCare is the dominant EHR in skilled nursing and senior living. The CCN Health integration enables real-time vital sign posting to resident charts, ADT event monitoring that automatically adjusts monitoring protocols, census sync for seamless enrollment, and care plan data exchange that informs alert thresholds.

What syncs:

• Real-time vital sign posting to PCC resident charts
• ADT events (admission, discharge, transfer) trigger automatic protocol changes
• Census data for patient enrollment and disenrollment
• Care plan information including monitoring thresholds and goals

Primary care settings: Skilled nursing facilities, senior living communities, memory care units, CCRCs

For a Charm Health practice managing patients in a PCC-powered facility, the dual-EHR integration means the physician sees billing-ready documentation in Charm Health while the facility's nursing staff sees device readings in their PCC workflow — without either side doing extra work.

View all PointClickCare integration guides

ALIS

Connection method: API integration with automated data exchange

ALIS is built for senior living operations — assisted living, memory care, and independent living communities. The CCN Health integration delivers automated vital sign charting in ALIS resident records, demographic sync for enrollment, and alert notifications that reach facility care teams through their existing ALIS workflows.

What syncs:

• Automated vital sign charting in resident records
• Resident demographic data for enrollment and identity matching
• Alert notifications routed to facility staff through ALIS
• Clinical documentation for care coordination

Primary care settings: Assisted living, memory care, independent living, senior living communities

For independent practices, the ALIS pairing is especially common. Many small physician groups serve patients across multiple assisted living communities — the Charm Health + ALIS bridge allows a single practice to manage RPM and CCM programs across all of them from one billing system.

View all ALIS integration guides

MatrixCare

Connection method: API integration with documentation alignment

MatrixCare serves skilled nursing, senior living, and home health organizations with a particular strength in MDS documentation and PDPM-aligned billing workflows. The CCN Health integration layers RPM data directly into MatrixCare's clinical record, with automated vitals flow and care transition management built into the connection.

What syncs:

• Automated vital sign flow into MatrixCare clinical records
• MDS documentation support with RPM data informing assessments
• PDPM-aligned billing data for facility-side revenue optimization
• Care transition management for patients moving between care levels

Primary care settings: Skilled nursing facilities, post-acute care, long-term care, home health

The MatrixCare pairing is valuable for practices managing patients in post-acute and long-term care settings where PDPM documentation directly affects facility reimbursement. RPM data flowing into MatrixCare strengthens the facility's clinical documentation while the physician practice bills through Charm Health.

View all MatrixCare integration guides

August Health

Connection method: API integration with resident engagement features

August Health is a modern EHR platform designed for senior living with strong family communication capabilities. The CCN Health integration connects resident records, medication management data, and the family communication portal — enabling monitoring data to reach not just the clinical team but also family members who want visibility into their loved one's care.

What syncs:

• Resident record sync for enrollment and clinical context
• Medication management data for reconciliation and alert context
• Family communication portal updates with monitoring summaries
• Clinical documentation for care coordination

Primary care settings: Assisted living, memory care, independent living, luxury senior living

For Charm Health practices, the August Health pairing opens access to a growing segment of modern senior living communities that prioritize family engagement. Monitoring data flowing to the August Health family portal means families stay informed without the practice fielding additional calls.

View all August Health integration guides

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Supported Medicare Programs

Through the CCN Health integration, Charm Health practices can bill all five Medicare care management programs. Each program generates its own CPT-ready documentation, time tracking records, and clinical notes — all routed automatically to Charm Health for claims submission.

2026 CMS Rate Schedule

Program	CPT Code	Description	2026 Rate
RPM	99453	Initial device setup and patient education	$21.71 (one-time)
	99454	Device supply, daily monitoring (30-day)	$52.11/mo
	99457	Clinical staff time, first 20 min/mo	$51.77/mo
	99458	Clinical staff time, additional 20 min/mo	$41.42/mo
	99091	Physician data review, 30+ min/mo	$58.48/mo
CCM	99490	Care coordination, first 20 min/mo	~$62/mo
	99491	Physician-led CCM, first 30 min/mo	~$86/mo
	99439	Additional 20 min/mo (add-on)	~$47/mo
PCM	99424	Physician PCM, first 30 min/mo	~$88/mo
	99425	Physician PCM, additional 30 min/mo	~$61/mo
	99426	Clinical staff PCM, first 30 min/mo	~$68/mo
	99427	Clinical staff PCM, additional 30 min/mo	~$54/mo
BHI	99484	BHI care management, 20+ min/mo	~$53/mo
	99492	Psychiatric CoCM, initial 70 min/mo	~$145 (initial)
	99493	Psychiatric CoCM, subsequent 60 min/mo	~$130/mo
RTM	98975	RTM device setup and education	~$19 (one-time)
	98976	RTM device supply, respiratory (30-day)	~$50/mo
	98977	RTM device supply, musculoskeletal (30-day)	~$50/mo
	98980	RTM treatment management, first 20 min	~$48/mo
	98981	RTM treatment management, additional 20 min	~$38/mo

Program Eligibility by Clinical Profile

Each program targets different patient needs, and a single patient may qualify for multiple programs simultaneously:

• RPM — Patients with chronic conditions requiring physiologic monitoring (blood pressure, weight, glucose, SpO2). Requires a qualifying diagnosis and an order from the billing physician.
• CCM — Patients with two or more chronic conditions expected to last at least 12 months. The most broadly applicable program for senior care populations.
• PCM — Patients with a single high-complexity chronic condition that requires intensive physician management. Cannot be billed alongside CCM for the same patient.
• BHI — Patients with behavioral health conditions (depression, anxiety, cognitive decline) that benefit from integrated psychiatric care management. Billable alongside RPM and CCM.
• RTM — Patients in therapy programs (respiratory therapy, physical therapy, occupational therapy) where outcome tracking supports treatment adjustments.

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Billing and Reimbursement Through Charm Health

Who Bills and Where

In every Charm Health dual-EHR configuration, billing follows the same rule: the ordering physician practice submits all Medicare claims through Charm Health. The facility EHR handles clinical documentation within the care setting, but it does not submit billing for RPM, CCM, PCM, BHI, or RTM.

CCN Health generates CPT-ready billing documentation — including time logs, clinical activities, device transmission records, and program-specific encounter data — and routes it directly to Charm Health. The practice's billing staff (or billing service) submits claims from there using standard Medicare workflows.

This means the facility does not need to change its billing processes. The facility EHR captures clinical data for care delivery. Charm Health captures billing data for reimbursement. CCN Health ensures both systems have what they need without manual transfer.

Revenue Stacking: What a Single Patient Can Generate

Medicare allows certain care management programs to be billed concurrently for the same patient when clinical criteria are met. For a Charm Health practice, this means a single patient can generate revenue from multiple programs simultaneously.

Example: Patient with hypertension, diabetes, and depression

Program	Codes Billed	Monthly Revenue
RPM	99454 + 99457 + 99458	$145.30
CCM	99490 + 99439	$109.00
BHI	99484	$53.00
Total		$307.30/mo

Example: Patient with a single high-complexity chronic condition (e.g., advanced COPD)

Program	Codes Billed	Monthly Revenue
RPM	99454 + 99457	$103.88
PCM	99424	$88.00
Total		$191.88/mo

For an independent practice managing 50 patients enrolled across multiple programs, these figures add up to meaningful recurring revenue — revenue that is often left uncaptured because practices lack the infrastructure to track time, generate documentation, and submit claims across five programs simultaneously.

Maximum Monthly RPM Revenue Per Patient

Using full RPM code stacking with 2026 CMS rates:

Code	Rate
99454	$52.11
99457	$51.77
99458	$41.42
99091	$58.48
RPM subtotal	$203.78/mo
99453 (setup, month 1 only)	$21.71

When additional programs are layered on top — CCM, PCM, BHI, or RTM — per-patient revenue increases further. The key constraint is clinical eligibility: each program requires documented medical necessity and qualifying diagnoses.

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Getting Started

Deploying the Charm Health dual-EHR integration follows a structured process that does not require custom development work on either the practice or facility side.

Step 1: Integration Configuration

CCN Health establishes the REST API connection with Charm Health and the corresponding integration with the facility EHR (PointClickCare, ALIS, MatrixCare, or August Health). API credentials are provisioned, data mapping is configured, and bidirectional sync is verified. This step is handled entirely by the CCN Health team.

Step 2: Patient Enrollment and Data Sync

Patient demographics from the facility EHR sync into CCN Health, matched against the practice's patient roster in Charm Health. Eligible patients are identified for RPM, CCM, and other programs based on their diagnoses, care setting, and clinical profile. Enrollment documentation — including physician orders and patient consent — is generated and routed to Charm Health.

Step 3: Device Deployment and Monitoring Activation

RPM devices are assigned to enrolled patients at the facility. Blood pressure monitors, weight scales, glucose meters, pulse oximeters, or contactless monitors are configured based on clinical need. Readings begin flowing through CCN Health to both the facility EHR (for nursing staff) and Charm Health (for the physician) immediately upon activation.

Step 4: Billing Documentation and Claims Submission

As monitoring data accumulates and clinical staff time is tracked, CCN Health generates CPT-ready billing documentation for each enrolled patient across all applicable programs. This documentation routes to Charm Health automatically, where the practice's billing staff can submit claims through their standard Medicare workflow. Monthly billing summaries, compliance reports, and program performance dashboards are available to the practice through CCN Health.

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Built for the Independent Practice Workflow

Large health systems have integration teams, IT departments, and dedicated billing staff to manage multi-program Medicare enrollment. Independent practices and small groups do not. They need an integration that works within their existing Charm Health workflow — not one that requires them to adopt a second EHR, hire additional staff, or manage a complex middleware layer.

CCN Health's Charm Health integration is designed for exactly this reality. The practice continues to use Charm Health as its primary clinical and billing platform. Monitoring data, clinical documentation, and billing records appear in Charm Health automatically. The facility continues to use its own EHR without disruption. And the gap between where care is delivered and where it is billed closes permanently.

One practice EHR. Four facility EHR pairings. Five Medicare programs. Zero manual data transfer.

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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.