A scalable, profitable remote care service line for AMS Cardiology: remote monitoring and principal care management for the Medicare cardiology panel your physicians already manage, billed under AMS’s own NPIs and run by a CoachCare care team inside eClinicalWorks
Cardiology is managed in the months between appointments. Four changes in how Medicare pays and measures that care are arriving together, and each one lands in the same place: the heart-failure patient whose weight climbs in week three, the hypertensive patient whose new agent needs a second dose change, the patient sent home from the hospital on Friday.
AMS Cardiology is an independent cardiology group in Horsham, Montgomery County, with 19 cardiologists and eight nurse practitioners and physician assistants across four sites, including its own outpatient surgery center for catheterization and stents. The Medicare panel is large and complex: about 13,000 Medicare patients, averaging 77 years old in traditional Medicare, with an average CMS risk score of 1.79 and heart failure in one patient of every three. AMS already follows implanted cardiac devices remotely for about 1,700 patients and runs eClinicalWorks at every site.
An older, high-risk Medicare panel, average age 77, in which hypertension is near-universal and a third of patients carry heart failure.
33% of AMS’s traditional-Medicare patients carry a heart-failure diagnosis. Weight and blood pressure change days before symptoms do, and a scale at home catches the change while a diuretic adjustment can still keep the patient home.
At least 75% of AMS’s traditional-Medicare patients have hypertension, and 47% have ischemic heart disease. Home readings give the physician a real average to titrate against instead of one office reading every few months.
39% have atrial fibrillation, 37% chronic kidney disease and 35% diabetes. Rate, blood pressure and kidney function move together, and a monthly care-management call keeps anticoagulation and labs on schedule.
Each step below added physicians, sites or capability. Click through the years. The next step adds the part none of them covers: daily readings and a care team between visits.
Each part of AMS touches a patient at one moment: an office visit, an echo, a device check, a hospital consult, a procedure. A remote care service line connects them, so a patient who leaves one encounter is still being watched until the next one. Select any part of the practice to see what changes.
AMS’s cardiologists and advanced practice clinicians set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the eClinicalWorks system AMS already uses, from the first flag on a patient’s chart to the claim at month end.
The program starts with the panel, not a referral pad. eClinicalWorks already holds the diagnoses, ejection fractions, vitals, labs and medications. Patients with heart failure, uncontrolled hypertension, atrial fibrillation or a recent admission are flagged using criteria AMS’s cardiologists set, so the right patients surface at a follow-up visit, after an echo, or on an outreach list.
Example criteria. AMS’s cardiologists set and own the flag logic for each condition.
Patients enter at an office visit, after a test or procedure, or after a hospital stay. Each way leads into the same monthly loop: office visits, care management and physiologic monitoring, each one informing the next.
BP 160/94 on three agents. The cardiologist places the remote care order at the follow-up visit, or the enrollment specialist enrolls the patient before checkout.
Cellular cuff at home, a welcome call by phone, and how to take a reading that counts.
99453Home averages drive medication changes month to month; the PCM call keeps the cardiovascular care plan on track.
99454 · 99457 · 99426Office visits ↻ care management ↻ physiologic monitoring.
Flagged in eClinicalWorks when the discharge notice arrives. Scale and cuff ordered to the home.
Contact within two business days, medication reconciliation, an AMS visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99426Office visits ↻ care management ↻ physiologic monitoring.
The cardiologist orders from the chart, or a CoachCare enrollment specialist working in the office enrolls the patient during the visit.
Cellular devices arrive ready to use. No Wi-Fi, no smartphone and no home internet needed, and nothing for the patient to pair.
The patient’s assigned care manager walks through the device, the routine, and who to call. The routine is set to fit the patient’s day.
Readings reviewed, outreach logged, care plan updated, escalations routed. Repeats every month.
From the enrollment flag in eClinicalWorks to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every office.
Readings that settle are logged in the chart and visible to the cardiologist without paging anyone.
Out-of-range readings get a retake and symptom check first. A confirmed trend goes to the clinician or nurse AMS designates, in eClinicalWorks, with the readings and a recommended next step attached.
Chest pain, new shortness of breath, fainting or stroke signs reported on a call: the care team calls 911 with the patient on the line, then notifies the office. A critical reading on its own goes to the office. This cannot be configured away.
At month end, three things come out of the program: clean claims in eClinicalWorks, an operational report for the practice’s leadership, and a clinical outcomes report for the physicians.
CoachCare is the only care-management application integrated with eClinicalWorks that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the practice. Sample below at the modeled month-12 census.
A 24-month forecast for an AMS remote care service line: remote monitoring and principal care management across the Medicare cardiology panel, priced at CY2026 Medicare rates for metropolitan Philadelphia with every patient priced at the Medicare amount, alongside what the program does for patients and for the people who run it.
Two cardiology follow-ups a year leave 363 days with no data. RPM bills only when a patient takes readings on at least 16 days in a month, so an enrolled patient gives the care team at least 192 days of readings a year.
The two outcomes a cardiology group cares about most, blood pressure and readmissions, have both been published from CoachCare programs at physician-owned cardiology practices.
Cardiac Solutions, a physician-owned cardiology practice with three West Phoenix offices, put 2,738 patients on CoachCare RPM with home blood-pressure monitoring.
AMS’s clinicians are MIPS-eligible for 2026, so every Medicare Part B payment they receive two years out moves with the quality score. The cardiology measures depend on work this program does every month. Select a measure to see how.
Monitoring the panel every day tells the practice who needs to be seen now, not only who is next on the schedule. Patients surface from their home data, not only when they come in sicker.
AMS cardiologists see patients in the hospital every week. The 30 days after discharge decide whether a patient comes back, and remote monitoring and principal care management carry the patient past them.
Flagged in eClinicalWorks for post-discharge monitoring.
A call within two business days and medication reconciliation.
Readings start right away. 99445 bills the short first month.
Monthly RPM with PCM while it adds value.
Daily weight and BP from day two, three touches inside two weeks, and GDMT steps scheduled while the patient is watched.
Blood pressure and heart rate while new medications settle, and a check that cardiac rehab has started.
Rate and blood pressure after a cardioversion, an ablation or a new rate-control agent.
Weight, blood pressure and symptoms until the first AMS follow-up, with a call when something changes.
Every code the service line can bill, at CY2026 Medicare rates for metropolitan Philadelphia. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, Pennsylvania locality 01, Metropolitan Philadelphia (Novitas, MAC 12502). Only one device code (99454 or 99445), one first-tier management code (99457 or 99470) and one care-management program bill for a patient in a given month. About 37% of Montgomery County’s Medicare beneficiaries are in Medicare Advantage. Those plans must pay at no less than the Medicare rate, a floor; individual contracts set their own terms for the care-management code families, and the forecast prices every patient at the Medicare amount.
AMS can start with remote monitoring alone, or run monitoring and principal care management together. Either way the program is net-positive. Select a deployment to redraw the charts.
| Full service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Unique patients, end of period | 960 | 2,191 | 2,191 |
| Contribution margin | $247,684 | $1,055,324 | $1,303,008 |
| Contribution margin runs −$5,567 in month 1 while the program ramps; positive from month 2. | |||
Change the assumptions and the 24-month forecast recalculates. Start from a deployment or move the sliders yourself. AMS’s own Medicare chart count is the first thing to plug in, and the onboarding pace slider shows how much enrollment capacity matters at this panel size.
CoachCare hires, trains and manages the care managers who run the program, at a caseload of 165 patients each. Drag the slider to see the team grow with the census.
AMS’s cardiologists, nurse practitioners, physician assistants and nurses keep doing clinical work. The monitoring, outreach and paperwork belong to CoachCare.
Monitoring, outreach and documentation over 24 months, on CoachCare’s payroll.
Hired, trained and managed by CoachCare. AMS would otherwise need to recruit and keep them.
The enrollment specialist working in AMS’s offices and device logistics are CoachCare’s expense.
Direct integration with the eClinicalWorks system AMS already runs, using its built-in workflows. Physicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
eClinicalWorks integration overviewThe staff, protocols and eClinicalWorks workflow built for remote monitoring and principal care management can take on the next programs AMS’s patients qualify for, without a second hiring plan.
AMS cardiologists billed about 2,260 initial hospital visits for traditional-Medicare patients in CY2024, and claims show no transitional care management at meaningful scale. The same care team can make the two-business-day call after each cardiac discharge, so the follow-up visit AMS already schedules can qualify as TCM, billed by AMS.
Patients scheduled for a catheterization, a stent, an ablation or a device implant can go on blood pressure, heart rate and weight before the procedure and stay on them through recovery, with the same care team and the same chart.
AMS already follows about 1,700 patients’ pacemakers, defibrillators and loop recorders remotely. Those transmissions report rhythm and device function, not blood pressure or daily weight. Adding a cuff and a scale for device patients with heart failure puts both data streams in the same eClinicalWorks chart.
Six reasons this partnership fits AMS specifically, not remote care in general.
AMS already reads implanted-device transmissions for about 1,700 patients, runs a nurse-led Coumadin clinic with home INR testing, and brings patients back through its own cardiac rehab program. Remote monitoring and principal care management apply the same between-visit discipline to blood pressure, weight and the heart-failure care plan.
Built on eClinicalWorks’ own workflows. Readings, documentation and claims live in the chart, and enrollment status is visible at every office.
CoachCare’s care managers carry the caseload at 165 patients each. Enrollment, devices, business-hours alert triage and billing preparation are on CoachCare’s payroll, with no capital outlay.
AMS’s physicians and advanced practice clinicians set the protocols, sign the care plans and make every clinical decision. Claims go out under AMS’s own billing entity and NPIs.
AMS’s traditional-Medicare patients average 77. Cellular devices need no home internet, no smartphone and nothing to pair, and outreach runs by phone, so no patient has to learn an app.
A 29.1 mmHg drop in Stage 2 hypertension across 2,738 patients at Cardiac Solutions (case study), half the 30-day readmission rate across 26,689 patients at the same practice (case study), and zero readmissions among 450 advanced heart-failure patients at Iowa Heart (case study).
The ask: a working session to confirm AMS’s Medicare chart count by payer, agree on the heart-failure and hypertension flag criteria, scope the eClinicalWorks integration, and set enrollment staffing for the Welsh Road and North Wales offices before the first patient enrolls.
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