Epic Integration
Chronic Care Management with CCN Health's Epic Integration
How CCN Health delivers Chronic Care Management through seamless Epic integration — automated documentation, real-time alerts, and Medicare billing built in.
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Not ready for a call? No problem. Drop us a message and we'll get back to you within 24 hours with answers to your questions about Chronic Care Management for your facility.
Tell us about your organization
Share details about your facility, current EHR setup, and what you're looking to achieve.
We'll review and respond
Our team will assess your needs and send you relevant information, case studies, or suggest next steps.
Connect when you're ready
When the time is right, we'll schedule a personalized demo tailored to your workflows.
Send Us a Message
We'll get back to you within 24 hours.
CCN Health provides a certified Chronic Care Management (CCM) integration with Epic. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
What is Chronic Care Management with Epic?
Chronic Care Management represents a proven clinical opportunity for organizations using Epic. CCN Health's integration automates the technical complexity — from device data capture to billing documentation.
Coordinated care for patients with two or more chronic conditions. Includes care plan development, medication management, and monthly check-ins with automated time tracking.
How It Works
- Patient Enrollment — Identify Medicare patients with 2+ chronic conditions and obtain consent
- Care Plan Creation — Develop comprehensive care plan addressing all chronic conditions
- Monthly Coordination — Regular check-ins, medication reconciliation, and care plan updates
- Epic Documentation — Care coordination notes and time logs sync to Epic automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Key Features
| Feature | Details |
|---|---|
| EHR Integration | Bi-directional sync with Epic |
| Devices Supported | Blood pressure, weight, SpO2, glucose, sensorless |
| Alert Time | Real-time notifications to care staff |
| Billing Codes | 99490, 99491 |
| Compliance | HIPAA compliant, CMS-aligned documentation |
| Platform Uptime | 99.9% availability |
Qualifying Conditions
| Condition Category | Examples | Key Metrics |
|---|---|---|
| Cardiovascular | Heart failure, hypertension, CAD | BP, weight, medication adherence |
| Metabolic | Diabetes, thyroid disorders | Glucose, weight, lab coordination |
| Respiratory | COPD, asthma | SpO2, respiratory rate, symptoms |
| Renal | CKD stages 3-5 | Weight, BP, fluid balance |
| Neurological | Dementia, Parkinson's | Cognitive screens, fall risk, ADLs |
Clinical Benefits
- Proactive management of multiple chronic conditions
- Reduced hospital readmissions through regular monitoring
- Improved medication adherence and reconciliation
- Better care coordination across providers
Billing & Reimbursement
CCN Health automates Medicare CCM billing documentation:
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99490 | ~$62/mo | 20+ minutes of clinical staff time per month |
| 99491 | ~$83/mo | 30+ minutes of physician/QHP time per month |
Monthly potential per patient: $62+
Ready to Get Started?
CCN Health handles everything — Epic integration setup, care plan templates, staff training, and ongoing clinical support. Most practices are fully operational within 2-4 weeks.
Frequently Asked Questions
Does CCN Health integrate directly with Epic for CCM?
Yes. CCN Health has a certified integration with Epic that enables bi-directional data flow. Vital signs and clinical data automatically appear in Epic patient records.
What are the billing requirements for CCM?
99490 requires 20+ minutes of clinical staff time per month. CCN Health tracks all requirements automatically and generates documentation for compliant billing.
Can CCM data be used across other programs?
Yes. CCN Health's platform enables cross-program data sharing. CCM data is available for use in RPM, CCM, PCM, and BHI programs without re-entry.
Configurable Alerts
Set thresholds that match your clinical protocols
Flexible Workflows
Adapt routing, documentation, and permissions to your team
Automated Compliance
Real-time audit trail and billing validation
Advanced technology working behind the scenes — so your team gets faster processing, smarter alerts, and effortless documentation without changing how they work.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Healthcare Organizations Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
EHR Integration
Bi-directional data sync with your existing EHR eliminates manual charting and reduces documentation errors.
Revenue Generation
Automated Medicare billing documentation captures every eligible reimbursement opportunity.
Clinical Outcomes
Real-time alerts and trending data enable early intervention before conditions deteriorate.
Built-In Efficiency
Automated workflows handle documentation, threshold management, and billing preparation — freeing clinical staff for direct patient care.
Family Engagement
Proactive monitoring gives families confidence in the quality of care being delivered.
Compliance & Reporting
Timestamped documentation supports regulatory compliance and quality measure reporting.
Questions?
Want to learn more about Chronic Care Management for your facility?
Our team can answer your questions and show you how it works with your current workflow.
Seamless EHR Integration
How CCN Health Works Inside Epic
Your program data flows directly into Epic — no exports, no manual entry, no disruption to your clinical workflow.
Care Coordination
Calls, Assessments, Care Plans
Built Around How You Operate
Custom workflows, smart alerting, and automated documentation — advanced technology working behind the scenes so your team doesn't have to.
Epic
Charts & Care Plans
What Flows Between Systems
Patient Demographics
Chronic conditions, medications, and problem lists from your EHR
Care Plan Updates
Treatment plans and goals sync bi-directionally
Contact Logging
Phone calls and check-ins documented with timestamps
Medication Reconciliation
Current medication lists kept in sync across platforms
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99490/99491 records generated automatically
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Common Questions
Frequently Asked Questions
Everything you need to know about Chronic Care Management — implementation, billing, and clinical workflows.
Yes. CCN Health integrates with Epic via secure APIs, enabling RPM device data and care management documentation to flow into Epic's enterprise health records.
CCN Health transmits device readings and care coordination notes to Epic through FHIR-based APIs, ensuring clinical data is available within existing Epic workflows.
CCM is a Medicare program that reimburses providers for non-face-to-face care coordination for patients with two or more chronic conditions, billed under CPT codes 99490, 99439, and 99491.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Contact Us
Prefer to Send a Message?
Not ready for a call? No problem. Drop us a message and we'll get back to you within 24 hours with answers to your questions about Chronic Care Management for your facility.
Tell us about your organization
Share details about your facility, current EHR setup, and what you're looking to achieve.
We'll review and respond
Our team will assess your needs and send you relevant information, case studies, or suggest next steps.
Connect when you're ready
When the time is right, we'll schedule a personalized demo tailored to your workflows.
Send Us a Message
We'll get back to you within 24 hours.
Get Started
Ready to bring Chronic Care Management to your organization?
See how CCN Health can improve patient outcomes and generate new Medicare revenue — all within the EHR your staff already uses.