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Chronic Care Management Software That Pays for Itself
Chronic Care Management (CCM) is a CMS-reimbursed care delivery model for patients with two or more chronic conditions. Purpose-built CCM software automates care plan documentation, clinical time tracking, patient outreach, remote monitoring data capture, and CPT billing — enabling practices to run profitable CCM programs without adding administrative overhead.
A Comprehensive Platform to Optimize CCM Delivery
Effective chronic care management requires structured workflows, consistent patient touchpoints, accurate time documentation, and seamless billing. Our CCM software platforms are designed to make all four frictionless for care teams.
Care Plan Management
Structured, evidence-based electronic care plans for patients with hypertension, diabetes, COPD, CHF, CKD, and other chronic conditions — with problem list management, goal tracking, medication reconciliation, and care team coordination.
Remote Patient Monitoring
Integrate with cellular and Bluetooth-connected RPM devices to capture blood pressure, blood glucose, weight, pulse oximetry, and peak flow readings — automatically alerting care managers when readings fall outside clinical thresholds.
CCM Time Tracking & Billing
Automated clinical time capture for all CCM touchpoints — phone calls, secure messages, care plan updates, coordination activities. Generate CPT 99490, 99491, 99487, and 99489 claims automatically when monthly time thresholds are met.
CCM Software Features Built for Care Teams
Every module is designed to reduce documentation burden on care managers while improving patient outcomes and program profitability.
Population Health Dashboards
Identify high-risk patients with overdue care plan reviews, missed RPM readings, or approaching monthly time thresholds — and prioritize outreach accordingly from a single unified dashboard.
Patient Engagement Tools
Secure two-way messaging, automated appointment reminders, health education content delivery, medication adherence nudges, and self-monitoring apps that keep patients engaged between clinical touchpoints.
Automated CMS Billing
When a patient's monthly CCM time threshold is crossed, the system automatically generates the appropriate CPT claim — eliminating manual billing, reducing denials, and capturing revenue that manual processes miss.
Multi-Disciplinary Care Coordination
Enable seamless collaboration between primary care physicians, care managers, specialists, pharmacists, and social workers — with shared care plans, task assignments, and communication logs across the care team.
Compliance & Standards Coverage
Why Care Programs Succeed with Woltrio
We build CCM platforms that care managers actually want to use — because intuitive software drives adoption, and adoption drives program revenue and patient outcomes.
CCM Program Expertise
We have deep knowledge of CMS CCM billing requirements, consent rules, time documentation standards, and exclusion criteria — ensuring your platform is audit-proof from day one.
EHR-Integrated Workflows
Our CCM platforms integrate bidirectionally with Epic, Cerner, Athenahealth, and 50+ other EHRs via FHIR — pulling problem lists, medications, and demographics without manual re-entry.
Measurable Program ROI
We build outcome tracking dashboards that demonstrate clinical improvement (HbA1c reduction, blood pressure control, readmission reduction) and financial ROI — critical for program sustainability and payer negotiations.
Our CCM Platform Implementation Process
From program design to full deployment, we set your CCM program up for clinical and financial success.
CCM Program Assessment
Evaluate your eligible patient population, existing care management workflows, EHR environment, and billing infrastructure.
Platform Configuration
Configure care plan templates for your chronic condition mix, time tracking rules, alert thresholds, and billing code mapping.
EHR & Device Integration
Implement FHIR-based EHR integration for patient data sync and connect RPM devices from your selected hardware partners.
Staff Onboarding & Training
Train care managers, physicians, and billing staff on the platform — with workflow guides, video training, and live Q&A.
Program Launch & Optimization
Launch with an initial cohort, monitor time capture rates, billing efficiency, and patient engagement — then optimize program workflows monthly.
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