Ethizo RPM & CCM Integration Guide 2026

The Dual-EHR Reality for Senior Care Physicians

Senior care physicians operate in a fundamentally different workflow than office-based primary care. A geriatrician or post-acute medicine specialist does not see patients in a clinic waiting room all day. They round at skilled nursing facilities, assisted living communities, memory care units, and CCRCs — often visiting three or four facilities in a single day. Each of those facilities runs its own EHR. PointClickCare at the SNF down the road. ALIS at the assisted living community across town. MatrixCare at the post-acute facility on the other side of the county.

But the physician documents and bills through their own practice EHR — Ethizo, which is specifically designed for the senior care physician workflow. Referral management, rounding schedules, billing documentation, and care plan coordination all live in Ethizo because it was built for this exact practice model.

This is the dual-EHR reality. Patient clinical data lives in the facility EHR. Physician documentation and billing live in the practice EHR. And when you add remote patient monitoring or chronic care management to the equation, the question becomes: how does monitoring data reach both systems without manual transcription, faxing, or duplicate data entry?

That is the problem CCN Health solves for Ethizo practices.

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How CCN Health Bridges Ethizo and Facility EHRs

CCN Health sits between Ethizo and the facility EHR, integrating with both systems simultaneously via secure API. Monitoring data from RPM devices flows in two directions — clinical readings post to the facility EHR for nursing staff workflows, while CPT-ready billing documentation routes to Ethizo for the ordering physician's claims submission.

Data Flow Architecture

Data Type	Source	Destination	Purpose
Patient demographics	Facility EHR	CCN Health	Auto-enrollment, resident identification
Vital sign readings	RPM devices	Facility EHR + Ethizo dashboard	Clinical workflows + physician review
ADT events	Facility EHR	CCN Health	Protocol adjustments on admission, transfer, discharge
Care plan data	Facility EHR	CCN Health	Monitoring thresholds informed by treatment goals
Billing documentation	CCN Health	Ethizo	CPT-ready records for Medicare claims submission
Care coordination notes	CCN Health	Facility EHR + Ethizo	Complete clinical context in both systems
Alert notifications	CCN Health	Facility EHR + Ethizo	Threshold violations surfaced to nursing staff and physician

Ethizo-Specific Integration Features

Vital Sign Dashboard — Device readings from all connected RPM monitors appear within Ethizo's patient vital sign dashboard. Physicians reviewing a patient chart in Ethizo see trending blood pressure, weight, glucose, and pulse oximetry data without opening a separate platform. This is critical for senior care physicians who manage large patient panels across facilities — switching between systems for every patient is not operationally feasible.

Referral Management — Ethizo's referral management capabilities integrate with facility ADT events flowing through CCN Health. When a patient is admitted to a facility, the referral status updates in Ethizo. When a patient transfers from assisted living to skilled nursing, the physician's Ethizo record reflects the change and monitoring protocols adjust automatically. This keeps the physician's patient roster current across every facility they serve.

Automated Billing Documentation — CCN Health generates time-tracked, CPT-coded billing records for all five Medicare programs and routes them directly to Ethizo. The physician practice does not need to manually compile monitoring logs, calculate time thresholds, or select CPT codes. Documentation arrives in Ethizo ready for claims submission — 99453 through 99458 for RPM, 99490 and 99491 for CCM, and the corresponding codes for PCM, BHI, and RTM.

Care Plan Synchronization — Care plans created in Ethizo and care plans documented in the facility EHR are both visible to CCN Health's monitoring engine. Alert thresholds, medication context, and treatment goals from both systems inform how device readings are evaluated. A blood pressure spike that would be routine for one patient might trigger an immediate escalation for another — the monitoring intelligence draws from both EHRs to make that determination.

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Facility EHR Pairings

CCN Health bridges Ethizo with four facility EHRs, covering the major platforms used across skilled nursing, assisted living, memory care, and post-acute settings.

PointClickCare

Connection: Direct API with bi-directional sync Care Settings: Skilled nursing, long-term care, CCRCs What Syncs: Real-time vital sign posting, ADT events, census data, care plan information, medication lists

PointClickCare is the dominant facility EHR in skilled nursing. For Ethizo physicians rounding at SNFs, the CCN Health integration creates a seamless data loop — resident demographics and census changes flow from PointClickCare into CCN Health for enrollment and protocol management, device readings post back to PCC resident charts for nursing workflows, and billing documentation routes to Ethizo for the physician's claims. ADT events in PointClickCare (admissions, transfers, discharges) automatically trigger protocol changes in CCN Health and update the physician's patient roster in Ethizo.

ALIS

Connection: API integration with automated data exchange Care Settings: Senior living, assisted living, independent living What Syncs: Vital sign charting, resident demographic data, alert notifications

ALIS powers senior living communities where many Ethizo physicians manage residents. The integration automates vital sign charting from RPM devices into ALIS resident records while routing billing documentation to Ethizo. Resident demographic data syncs from ALIS to CCN Health for enrollment, and alert notifications surface threshold violations to both the community's care staff (in ALIS) and the attending physician (in Ethizo). This pairing is one of the most common for senior care practices — ALIS communities frequently rely on external physicians for chronic condition management and Medicare program oversight.

MatrixCare

Connection: API integration with MDS documentation support Care Settings: Post-acute care, skilled nursing, senior living What Syncs: Automated vitals flow, MDS documentation data, PDPM-aligned billing information

MatrixCare serves post-acute and senior living settings where clinical documentation complexity is high. The CCN Health integration routes device readings into MatrixCare for clinical workflows and supports MDS documentation alignment — RPM vital sign data can inform MDS assessment sections without manual transcription. For the Ethizo physician, PDPM-aligned billing documentation flows to their practice EHR alongside standard CPT-coded records for Medicare program billing.

August Health

Connection: API integration with resident record synchronization Care Settings: Assisted living, memory care What Syncs: Resident records, medication management data, vital sign observations

August Health is designed for assisted living and memory care communities — settings where Ethizo physicians frequently manage residents with complex chronic conditions and cognitive impairment. The integration syncs resident records between August Health and CCN Health, enabling enrollment without duplicate data entry. Medication management data from August Health provides context for monitoring alert evaluation, and vital sign observations from RPM devices flow back to the resident record for care staff review.

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Supported Medicare Programs

All five Medicare care management programs are supported through the Ethizo integration. Billing documentation for each program generates automatically and routes to Ethizo for claims submission by the ordering physician.

Program	CPT Codes	2026 CMS Rates	Description
RPM	99453 (setup)	$21.71 (one-time)	Device setup and patient education
	99454	$52.11/mo	Device supply and daily data transmission
	99457	$51.77/mo	First 20 min clinical monitoring/month
	99458	$41.42/mo	Additional 20 min clinical monitoring
	99091	$58.48/mo	Data analysis and interpretation
CCM	99490	~$62/mo	20 min care coordination (2+ chronic conditions)
	99491	~$86/mo	Complex CCM, first 30 min (physician-directed)
	99439	~$47/mo	Additional 20 min care coordination
PCM	99424	~$88/mo	30 min physician management (complex condition)
	99426	~$68/mo	30 min clinical staff management
BHI	99484	~$53/mo	20 min behavioral health integration
RTM	98975 (setup)	~$19 (one-time)	Device/software setup for therapy
	98976/98977	~$50/mo	Device supply (respiratory/musculoskeletal)
	98980	~$48/mo	First 20 min clinical monitoring

Senior care patient populations are among the highest-qualifying demographics for multi-program stacking. A single resident with hypertension, diabetes, and depression qualifies for RPM (device monitoring), CCM (care coordination for multiple chronic conditions), and BHI (behavioral health integration) simultaneously — all billed through Ethizo under separate CPT codes.

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Billing and Reimbursement

All Medicare billing for RPM, CCM, PCM, BHI, and RTM flows through Ethizo. The facility EHR handles clinical data and resident management within the care setting, but the ordering physician submits claims through their practice EHR. CCN Health generates CPT-ready billing documentation — including time tracking, service descriptions, and code selection — and routes it to Ethizo automatically.

Revenue Stacking Examples

The following estimates use 2026 CMS rates for the national average. Actual reimbursement varies by geographic region and payer.

RPM Only

Code	Service	Monthly Rate
99454	Device supply and data transmission	$52.11
99457	First 20 min clinical monitoring	$51.77
Total		~$104/mo

This baseline captures device supply (99454) and the first 20-minute clinical monitoring block (99457). Most RPM-enrolled patients generate this minimum revenue if they meet the 16-day monthly transmission threshold and receive at least 20 minutes of clinical interaction.

RPM + CCM

Code	Service	Monthly Rate
99454	Device supply and data transmission	$52.11
99457	First 20 min RPM monitoring	$51.77
99490	20 min CCM care coordination	~$62.00
Total		~$166/mo

Adding CCM for patients with two or more chronic conditions — the majority of senior care patients — increases monthly revenue by roughly 60%. The CCM documentation captures care coordination activities that the practice is already performing: medication reconciliation, care plan updates, communication with facility nursing staff, and specialist referral management.

RPM Full Stack + CCM Extended

Code	Service	Monthly Rate
99454	Device supply and data transmission	$52.11
99457	First 20 min RPM monitoring	$51.77
99458	Additional 20 min RPM monitoring	$41.42
99490	20 min CCM care coordination	~$62.00
99439	Additional 20 min CCM coordination	~$47.00
Total		~$254/mo

For complex patients requiring extended clinical time — common among the geriatric population — stacking the additional RPM monitoring block (99458) and extended CCM coordination (99439) pushes monthly reimbursement above $250 per patient. Practices managing patients across multiple facilities often reach these time thresholds naturally because the care coordination involved in facility-based medicine is inherently time-intensive.

Why Billing Through Ethizo Matters

Ethizo is the billing system of record for the ordering physician. Medicare requires that RPM, CCM, and related programs be billed by the physician who orders and oversees the services — not by the facility. This means:

• All CPT codes are submitted through the physician's Ethizo-based billing workflow
• The facility EHR (PointClickCare, ALIS, MatrixCare, or August Health) does not handle billing for these programs
• CCN Health generates documentation that meets Medicare's time, transmission, and clinical interaction requirements and routes it to Ethizo in a format compatible with claims submission
• The physician practice retains full billing control and revenue attribution

This separation is critical. Facility EHRs are clinical documentation systems — they track resident care, medications, and nursing workflows. Ethizo is where the physician documents, manages referrals, and submits claims. CCN Health respects this boundary and routes data to the correct system based on its purpose.

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Getting Started

Step 1: Assess Your Patient Panel

Identify patients across your facility rounding list who qualify for RPM and CCM. Senior care practices typically find that 60-80% of their facility-based patients have at least one chronic condition qualifying for remote monitoring — hypertension, diabetes, COPD, heart failure, or CKD. Patients with two or more qualifying conditions are candidates for CCM stacking.

Step 2: Establish the Integration

CCN Health connects to Ethizo via secure API and simultaneously establishes connections with each facility EHR where you manage patients. API credential provisioning, demographic sync verification, and clinical workflow mapping are handled by the CCN Health team. The integration is pre-built for Ethizo and all four facility EHR partners — no custom development is required.

Step 3: Enroll Patients and Deploy Devices

Patients are enrolled through CCN Health using demographic data synced from the facility EHR. RPM devices are shipped directly to the facility or patient residence. Device readings begin flowing to both the facility EHR (for nursing workflows) and Ethizo (for the physician's vital sign dashboard) immediately upon activation.

Step 4: Monitor, Document, and Bill

CCN Health handles daily monitoring of incoming device data, clinical triage, and alert escalation. Billing documentation — time-tracked, CPT-coded, and compliant with Medicare requirements — generates automatically and routes to Ethizo for claims submission. The physician practice reviews escalated alerts, conducts required patient interactions, and submits claims through their normal Ethizo billing workflow.

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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 2026 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.