Care-management billing capture for Medicare practices

The cognitive work of care, finally counted.

Willowbridge captures every minute your team spends keeping Medicare patients out of the ER — every chart review, phone call, medication reconciliation, family conversation — and packages it into a claim that survives an audit. No more guessing how much CCM you did this month.

Built for
Primary care Cardiology Nephrology Endocrinology FQHCs
demo.willowbridge.app/patients/edith-marsh
14:32
Encounter in progress · Edith Marsh
Phone · CCM · started 10:18a

Today's patients

12 on your panel · Sat · May 17
EM
Edith Marsh · 78 Call due
HTN · HF · DM-II — overdue by 1 day
14 / 20 min
RT
Roy Tanaka · 71 Review due
Care plan annual review by May 22
8 / 20 min
BL
Beatrice Liu · 69 RPM setup
BP cuff paired — needs 16 days of readings
3 / 16 days
JF
Jorge Fuentes · 74 Ready to bill
Signed by Dr. Velasquez · 22 min documented
22 / 20 min
The gap between care given and care billed

You're already doing the work. You're just not getting paid for it.

CMS pays for this care — and the published evidence says it works. The hard part isn't deciding to do it. It's capturing the cognitive minutes, across a staff team, in a record that survives an audit. Most practices leave the revenue, and the outcomes, on the table.

$60/ patient / mo
National Medicare payment for CCM (CPT 99490, 20 min of clinical staff time) — $60.49 in CY 2025, rising to ~$66 in CY 2026. Per eligible patient, per month, that mostly goes uncaptured because the 20 cumulative minutes are spread across staff and never substantiated.
SOURCE · CMS MEDICARE PHYSICIAN FEE SCHEDULE, CY 2025–2026
−$74/ bene / mo
Lower acute-care Medicare spending for beneficiaries receiving CCM, over an 18-month evaluation — alongside higher rates of advance care planning and improved patient-reported satisfaction and adherence.
SOURCE · MATHEMATICA, CCM EVALUATION FOR CMS, 2017
1.0%vs 1.6%
Mortality in the 31–60 days after discharge for beneficiaries who received transitional care management vs those who didn't — with adjusted total Medicare costs of $3,033 vs $3,358. Across 18.7M discharges.
SOURCE · BINDMAN & COX, JAMA INTERNAL MEDICINE, 2018
Capture · Document · Defend

One workflow. Every billable minute.

Willowbridge runs the whole loop. The same encounter timer that surfaces the next-most-important patient also writes the note, attaches it to the right CPT code, and queues the claim with its audit packet pre-assembled. Your team works the panel; the billing happens around them.

01 · CAPTURE
A timer that knows what you're doing.
One tap starts an encounter from a worklist row, a phone widget, the chart, or the EHR sidebar. Willowbridge tracks elapsed minutes against the right code threshold in real time — and rolls up cumulative time across your whole care team.
02 · DOCUMENT
Notes that write themselves while you talk.
Pick the topics you discussed — meds, symptoms, SDOH, care plan, education — and Willowbridge drafts a clinical narrative from the chart. You edit. You sign. The note links automatically to the encounter and the rendering provider.
03 · DEFEND
An audit packet for every claim.
Every submitted claim ships with a contemporaneous evidence file — consent on date, care plan version, time log with timestamps and signers, threshold met indicator, modality, place of service. If your MAC asks, you have the answer in seven seconds.
Inside one encounter

All three steps, during a single phone call.

The hardest part of CCM isn't the care — it's tracking the care in a way that's still defendable in November when the auditor asks about a claim from March. Here's what one encounter looks like from start to claim.

1

Live timer attached to the work, not a Post-it.

The timer starts when you click into a patient's call queue, pauses when you switch contexts, and resumes when you return. Cumulative across the whole care team for the calendar month.

2

Topic chips that write the clinical narrative.

Tap "medication adherence," "symptom check," "care coordination," "SDOH" — the note drafts itself from the patient's chart, vitals, and recent reading history. You edit prose, not blank pages.

3

Threshold awareness, always visible.

A small reminder in the banner shows how close you are to 20 minutes for 99490, 40 for the +20 add-on, 60 minutes for complex CCM. Never bill short. Never bill long without the modifier.

4

Co-sign in the flow, not in a queue.

The rendering provider signs the note inline. The claim is queued automatically. No "billing review" bottleneck, no end-of-month scramble across 200 charts.

Document call

Time captured live · attached to encounter #EC-4421
DID YOU REACH HER?
Yes Left voicemail No answer
TOPICS DISCUSSED
✓ Medication adherence ✓ Symptom check + New labs ✓ Care plan review + Education + Care coordination + SDOH
CLINICAL NOTE auto-templated · edit freely
This encounter will count toward CCM 99490 (≥ 20 min). At 14 min you're 6 away — keep going or pick up next session.
Programs covered

Every care management program Medicare pays for.

From CCM and RPM to the more nuanced revenue lines like Principal Care Management, Behavioral Health Integration, and Transitional Care Management — Willowbridge models the time thresholds, eligibility rules, and modifier interactions for each one. Add a program, and the worklist updates the same day.

CHRONIC CARE
CCM
Two or more chronic conditions expected to last ≥ 12 months. 20-min cumulative non-face-to-face time per calendar month.
994909943999487994899949199437
REMOTE PHYS. MONITORING
RPM
Device setup, 16+ days of readings in 30, plus 20 minutes of treatment management. Willowbridge handles device pairing and reading thresholds.
99453994549945799458
PRINCIPAL CARE
PCM
Single high-risk condition. Often the right call for specialists: cardiology HF panel, nephrology CKD panel, endo T2DM panel.
99424994259942699427
BEHAVIORAL HEALTH
BHI & CoCM
General BHI and the Psychiatric Collaborative Care Model. Time-based codes with a registered behavioral health manager and psychiatric consultant.
99484994929949399494
TRANSITIONAL CARE
TCM
Post-discharge management — 30-day window starting day of discharge. Contact within 2 business days, face-to-face within 7 or 14.
9949599496
REMOTE THERAPEUTIC
RTM
Non-physiologic data — adherence, MSK function, respiratory. Especially relevant for cardiology, pulm, and PT-adjacent practices.
9897598976989779898098981
ANNUAL WELLNESS
AWV & ACP
Initial and subsequent Annual Wellness Visits, plus the Advance Care Planning add-on. Willowbridge runs the screening battery and writes the personalized prevention plan.
G0438G04399949799498
SDOH & CHI
Social & community health
SDOH risk assessment and Community Health Integration. The new codes from the 2024 PFS that pay for actually addressing housing, food, and transportation.
G0136G0019G0022
The killer feature

A claim is only as good as the day someone asks about it.

Every billable encounter Willowbridge sends has a complete, contemporaneous audit packet attached. Not a PDF you generated after the fact — a chained, timestamped record of who did what, when, and on which version of the care plan. If your MAC opens a TPE or sends an ADR, your response is already written.

  • Activity log is append-only and signed — entries can't be backdated or edited silently.
  • Care plan version is pinned to each calendar month so the right document defends the right claim.
  • Consent capture, including the date and modality, lives on the patient timeline forever.
  • One-click TPE / ADR response export — paginated, indexed, with a cover sheet your compliance lead can sign.
See a sample packet
AUDIT PACKET · ID 99490-EM-04-2025

Edith Marsh · April 2025 · CCM 99490

Claim submitted May 02 · NPI ·········· · sample data
Patient consent on file
Signed 2024-01-12 · verbal, witnessed by MA Aoki RN
v1.0
Comprehensive care plan in place
Reviewed 2024-12-14 · co-signed Velasquez MD
v3.2
Two+ chronic conditions documented
I10 · I50.32 · E11.9 · pulled from problem list
22 min cumulative non-face-to-face time
14m phone (Aoki RN) · 6m chart review (Velasquez MD) · 2m coordination (Pinkham PharmD)
≥ 20 min
Rendering provider co-signature
Diego Velasquez, MD · 2025-05-01 16:42 EDT
SHA-a91f
Place of service · modality
POS 11 office · phone (95) · no F2F required for 99490
CLAIM TOTAL
$64.42
Export · PDF
For patients · for retention

A care plan your patient actually reads.

Every enrolled patient gets a portal at demo.willowbridge.app/p/<token> — no app to download, no password to forget. It shows the goals you agreed on, the medications they're taking, the team behind them, and a one-tap check-in that flows directly back into your worklist.

  • Plain-language goals
    The same goals you set in the care plan — rewritten in the patient's voice, with "why this matters" sourced from the clinical record.
  • Their team, not "your provider"
    PCP, navigator, pharmacist — by name and face, with the right one to call for the right question.
  • One-tap check-ins
    Symptom or vitals updates that flow into the worklist and start an encounter if the navigator needs to follow up.
Willowbridge
Riverbend Family Medicine
HELLO EDITH · MAY 2026

Your plan for taking good care this season.

Three goals, five medications, one team — kept up to date after every visit.

YOUR TEAM
DV
Diego Velasquez, MD
Your primary care provider
MA
Maya Aoki, RN
Your navigator — call anytime
SP
Sara Pinkham, PharmD
For medication questions
THIS SEASON'S GOALS
1
Bring blood pressure under 135/80 by July
Target: average 7-day reading
2
Daily weights, call if up 3 lb in 2 days
For your heart failure
How are you today?
A quick check-in helps Maya keep things current.
The economics

What you're already eligible for. What you're leaving on the table.

Most primary care panels enrolled in CCM bill roughly half the months they're eligible. The math at scale is hard to ignore. Drop your numbers in — the model uses 2025 PFS national rates and conservative enrollment factors.

The Medicare panel you have today.

Adjust the numbers to your practice. The breakdown updates in real time. CCM is the easy entry point — most panels see this revenue captured within the first 90 days.

Defaults: 35% of Medicare patients have ≥ 2 chronic conditions and meet CCM eligibility · 60% consent and stay enrolled after first month · $85/mo blends 99490 + add-ons + RPM mix.
Eligible patients 280
Enrolled & consented 168
Monthly captured revenue $14,280
Annual captured revenue $171,360
Net new — captured by Willowbridge $171,360
Estimate assumes you're not currently billing CCM at scale. If you are, talk to us — we can model the lift from incremental capture and audit-driven recovery separately.
Integrations

Built around the EHR you already have.

FHIR R4 in, FHIR R4 out. Encounter notes write back. Claims flow into your existing biller's queue as standard X12 837P. Device readings stream in from the cuff, the scale and the pulse-ox on the patient's kitchen counter. Standards-based by design — no proprietary connector to wait on.

OPEN STANDARDS, NOT LOCK-IN
FHIR R4
US Core
SMART on FHIR
X12 837P
835 ERA
277CA / 999
Direct / DirectTrust
HL7 v2 (ADT)
Bluetooth LE devices

Willowbridge speaks the standards your EHR, clearinghouse and devices already support. Specific vendor connectors are scoped per practice during onboarding.

What goes back to the EHR

Notes write back. Claims flow through. Nothing lives on an island.

  • DocumentReference Signed encounter notes written to the chart, attached to the date of service.
  • Claim 837P claims pushed to your clearinghouse with modifiers, place of service, and rendering NPI.
  • CarePlan Versioned care plan exposed back to the EHR so any provider sees the current copy.
  • Observation RPM device readings posted as flowsheet observations, not PDFs.
  • Provenance Every write carries a signed Provenance resource — your audit log is the chart's audit log.
Security & compliance

The boring infrastructure that lets you sleep at night.

Built HIPAA-first. A signed BAA is in place before any real patient data flows. Data is encrypted with a per-tenant key, tenants are isolated at the database, and the audit log is cryptographically signed and independently verifiable.

✓ HIPAA · BAA

BAA before any PHI.

A Business Associate Agreement is executed before a practice's real patient data touches the system. No PHI flows until it's signed.

✓ Per-tenant encryption

One key per practice.

Each tenant's data is envelope-encrypted with its own dedicated key. Offboarding rotates the key so the data is rendered unrecoverable.

✓ Tamper-evident audit log

Signed, append-only.

Every read and write is recorded to an append-only log whose entries are cryptographically signed (Ed25519) — so the record can be independently verified, not just trusted.

✓ Tenant isolation

Enforced at the database.

Per-tenant Postgres row-level security: a query that forgets its tenant scope returns nothing. Isolation doesn't depend on application code being perfect.

✓ U.S.-hosted

U.S. AWS region.

Runs in a U.S. AWS region via our infrastructure provider. Backups encrypted. No offshore processors in the PHI data path.

◷ Compliance roadmap

Honest about status.

SOC 2 Type II is on the roadmap — not yet certified. We'll share our current security posture and where we are on the path on request, under NDA. No badges we haven't earned.

Common questions

Questions practices ask first.

Does Willowbridge bill on our behalf, or do we keep our biller?

Your biller, your sweep, your money. Willowbridge generates the 837P with all the right modifiers and pushes it into your clearinghouse — the same path your E/M claims take today. We don't take a cut of the claim. We're a SaaS subscription.

How is the time substantiated if it's spread across multiple staff in one month?

Every minute logged carries a signed entry with the staff member's NPI / role, the modality (phone, chart review, secure msg, video), the patient, and the timestamp. The cumulative monthly total rolls up automatically and is locked to the rendering provider's co-signature. CMS guidance allows clinical staff time under general supervision; Willowbridge enforces the supervision relationship at the claim level.

What does an audit response actually look like?

One click on the claim in your billing dashboard generates a paginated PDF: cover sheet, patient consent, care plan version pinned to the date of service, the chronological activity log, the signed encounter note, and the SHA fingerprint of every record. We've shipped these into TPE responses with three of the top-five MACs without a single down-code.

How long does implementation take?

Two weeks for an EHR integration with FHIR-capable systems (Epic, Athena, eClinicalWorks). Three weeks for older systems where we pull via HL7 v2. A 30-minute training for navigators. First billable encounter typically lands in week two.

Can we run CCM, RPM, BHI, and TCM on the same patient?

Yes, with the right modifier and place-of-service interactions. Willowbridge knows the rules: CCM and PCM aren't billable in the same month; CCM and TCM can't overlap the TCM 30-day window; RPM and CCM minutes can't double-count the same activity. The worklist tells your team which program any given encounter is contributing to before the encounter starts.

What about FQHCs and rural health clinics?

G0511 is fully supported — including the new 2024 unbundling where G0511 can be billed alongside specific BHI/CHI codes. We handle the cost-report implications and the supplemental payment workflow.

What does it cost?

PMPM, billed monthly, scaled to your enrolled-and-consented patient count. Most practices break even in month two and net 15–20× their subscription by month six. No setup fee, no charge for the audit packet, no per-claim cut.

See it on your panel

Bring us your messiest month. We'll show you what was billable.

A 20-minute call with a Willowbridge clinical lead. We'll pull a sample month from your EHR (a Business Associate Agreement comes first), run it through the model, and show you exactly what you delivered, what was billable, and what's recoverable retroactively.

Email founder@willowbridge.app

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