The hospital knows the day every patient goes home. In CY2024 nobody billed for the thirty days after it. This is the 24-month plan to own that window: a transitional care episode at every Medicare discharge, remote monitoring and care management through the Piedmont practices in Conyers, every step in Epic, staffed by CoachCare, priced at the Atlanta locality, with the heart-failure episodes of the Ambulatory Specialty Model starting in 2027.
Two counts, two jobs. The headline is 988 unique patients in the office-based programs at month 24; the enrollment chart and the Scenario Explorer show 1,516 active program enrollments, because a patient on both remote monitoring and chronic care management is one patient and two enrollments. Transitional care episodes (4,563 over 24 months) are counted separately.
A 161-bed community hospital that is the only acute-care hospital in its county, running a 34-bed emergency department at about 50,000 visits a year, a certified Chest Pain Center, a Primary Stroke Center with on-site neurohospitalists, interventional cardiology and a Level III NICU, and finishing FY2025 with $30 million of surplus on $293 million of revenue. The machinery a readmission-prevention program needs is already running.
Serving Conyers since 1954, part of Piedmont Healthcare since October 2017, and expanded to 161 beds with the intermediate-care and med-surg project completed in 2022. Every Medicare discharge in the county starts here.
Thirty-four beds, about 50,000 visits a year, 1% of patients leaving before being seen, and the first ENA Lantern Award in the Piedmont system. The emergency department is the front door for most of the discharges this plan works.
U.S. News 2025-26 rates the hospital High Performing in heart attack, heart failure, pneumonia, stroke and diabetes. Certified Chest Pain Center, Primary Stroke Center, interventional cardiology. The clinical side of the readmission problem is not the problem.
The hospital, Piedmont Heart at the hospital, and the Piedmont primary-care and specialty practices in Conyers share one Epic record. About 3,350 Medicare patients discharged in a year, an established Medicare panel of roughly 10,500 across the Conyers practices, and 34 referring clinicians in adult medicine.
One structural fact completes the picture: in CY2024 no transitional care management was billed by any Piedmont Conyers clinician, no remote monitoring, and chronic care management at trace volume (52 beneficiaries). Case management works the inpatient stay. Nobody is paid to work the thirty days after it.
CMS's FY2026 Hospital Readmissions Reduction Program penalizes the hospital on heart failure and COPD. Discharged patients accumulate excess return days after pneumonia and heart attack. The emergency department holds discharged patients 222 minutes. Against that, in CY2024 no Piedmont Conyers clinician billed transitional care management. The discharge is the one hand-off the hospital controls end to end, and the one nobody is paid for.
Five steps, every one of them in Epic, every one of them billable or feeding something that is.
Emergency, inpatient or observation. CoachCare's on-site enrollment specialist at the hospital works the discharge list with case management and enrolls the patient the same day.
TCM episode opensWithin two business days: medications reconciled against the discharge instructions, symptoms checked, the office visit booked, the device shipped or handed over.
99495 / 99496 requirementWith the patient's Piedmont internist, family physician or cardiologist in Conyers, within 7 days for high complexity or 14 for moderate.
$303.22 / $223.60Cellular blood pressure cuff, scale or glucometer set up at the visit; the 2–15-day monitoring window opens under the CY2026 code and the monthly stack follows.
RPM from day 7Chronic care management for the multi-condition patient, or principal care management for the heart-failure cohort in the Piedmont Heart clinic, from the same month.
CCM or PCMThe cadence runs whether or not the patient was admitted; when they were, it is also the transitional care episode. Anything trending is escalated through the engine in the governance section below.
Reach the patient, reconcile medications, confirm the device is transmitting, confirm the office visit.
Symptom and reading review, barriers to the plan, the 7-day visit completed for the high-complexity cohort.
Close the episode or extend it; the 14-day visit completed; the monthly program takes over.
New monitoring codes that fit the post-discharge window, heart-failure episodes under the Ambulatory Specialty Model beginning in 2027, and an ACO that shares in the savings with no downside.
New CPT codes for 2 to 15 days of device data and for the first 10 minutes of management remove the 16-day floor that used to block episodic monitoring. A discharge can now be followed by a billable two-week window, next to the standard monthly stack. On this forecast the two codes carry $293,595 over 24 months, about 9.0% of the office-based net reimbursement.
The Atlanta metropolitan division is a selected geography, and 16 physicians billing under Piedmont Cardiology of Atlanta, LLC are named on the CMS preliminary participant list for the Ambulatory Specialty Model, Heart Failure cohort; 10 of them carry a Conyers practice location and 7 hold a Care Compare affiliation with Piedmont Rockdale Hospital. The payment adjustment is ±9% for the first two performance years, rising to ±12%; the first performance year is CY2027, paid in payment year 2029.
The Conyers practices participate in Piedmont Clinic ACO LLC through their parent billing entities: Medicare Shared Savings Program, BASIC track Level B, 120 participant TINs. Transitional care and 30-day readmissions both flow to shared savings, and there is no downside risk on the track.
Chronic care management, principal care management and transitional care management open heart-failure episodes and count toward the 30% attribution threshold; remote monitoring does not. So transitional care at every heart-failure discharge and principal care management in the Piedmont Heart clinic are the codes that matter for the model. A Collaborative Care Arrangement runs between the participating specialist and a primary-care practice; CoachCare is not a counterparty to it. CMS has proposed for CY2027 that the arrangement may also cover in-kind care managers or technology infrastructure. That is a proposal, not a final rule.
Every figure on this page is priced at the CY2026 Physician Fee Schedule non-facility amounts for Georgia locality 01 (Atlanta), Palmetto GBA, ZIP 30012: transitional care $223.60 and $303.22 per episode, device supply $53.00 a month, chronic care management $67.19 a month. Rockdale County is 65.2% Medicare Advantage. Medicare Advantage plans must pay at least the Medicare rate — a floor; individual contracts set their own terms for the care-management code families.
Georgia Medicaid fee-for-service does not reimburse remote patient monitoring, so the forecast on this page is Medicare only, traditional and Medicare Advantage.
A named service line with its own P&L and scorecard: the discharge lane the hospital owns, and the office-based follow-up the Piedmont practices in Conyers deliver, both inside the Epic record they already share. Modeled on the primary-care and internal-medicine row because the discharged population is multi-morbid and the follow-up lands in primary care.
Piedmont launched a system-wide chronic care management and remote monitoring program with an outside partner in August 2025, starting in primary care and integrated with Epic. That program covers monthly care management and monitoring for enrolled primary-care patients. What it does not cover is the discharge itself: no transitional care management was billed by any Piedmont Conyers clinician in CY2024, no remote monitoring, and chronic care management at trace volume (52 beneficiaries; the CY2024 file predates the August 2025 launch). CoachCare owns the discharge-to-transitional-care lane and the post-discharge enrollment from the hospital. Where the existing program already holds a patient's care management, the transitional care hand-off lands in that program. The two co-exist; the overlap is the second item on the discovery agenda.
This is the hospital's service line, its patients, its protocols, its claims and its revenue. Case management keeps the inpatient stay; the program takes the thirty days after it and the months between visits. Enrollment outreach, care managers and device logistics are CoachCare's payroll, embedded in the fee, never deducted from the hospital's margin. About 13.0 FTE-years of care-team work in the office-based forecast, plus 4,563 hours on the transitional care episodes, none of it on the hospital's staffing plan.
| Service | Codes | CY2026, Georgia locality 01 | Use across the discharge cohort |
|---|---|---|---|
| Transitional care management | 99495 · 99496 | $223.60 / $303.22 per episode | Every Medicare discharge captured into an episode; the wedge, modeled as its own line |
| RPM setup and device supply | 99453 · 99454 · 99445 (new) | $22.18 setup · $53.00/mo | Heart-failure, hypertension and diabetes cohorts; 99445 opens 2–15-day windows after a discharge |
| RPM treatment management | 99457 · 99458 · 99470 (new) | $52.58 + $42.06 add'l · $26.46 | Monthly review, titration, escalation |
| Chronic care management | 99490 · 99439 | $67.19 + $51.25 add'l | Two or more chronic conditions; the longitudinal wrapper through the Conyers primary-care practices |
| Principal care management | 99426 · 99427 | $68.89 + $54.98 add'l | The heart-failure cohort in the Piedmont Heart clinic; opens Ambulatory Specialty Model episodes; not in the forecast |
Rates are the CY2026 Physician Fee Schedule non-facility amounts for ZIP 30012 (Palmetto GBA, Georgia locality 01, Atlanta), the basis the Value Analysis below is priced on.
CoachCare uses Epic's own workflows, so the hospital and the Conyers practices enroll and monitor patients without learning a second system. The program lives in the Epic environment: enrollment flags and orders leave the chart; device readings, care documentation, enrollment status and billing-ready claims come back into it. Patients begin receiving services in under five days from the flag, and CoachCare is the only care-management application integrated with Epic that generates the claims automatically.
Enrollment flags and trigger ordering inside the clinical workflow; CoachCare enrolls qualifying Medicare patients on the practice's behalf; status visible in Epic in real time. For this account, the discharge event is the trigger.
Bi-directional at intake, so the care team starts from the discharge summary and the medication list, not a blank chart.
Device readings land as discrete vitals in the chart, not as PDFs, where the internist and the cardiologist already look.
The transitional care contact, the care plan and every monthly summary written to the record, audit-ready.
99495/99496, the monitoring stack and the monthly care-management claims generated by the CoachCare billing engine, every patient, every month.
the integration is built alongside onboarding, training and care-team assignment; the first enrollments do not wait for it.
a discharge event or a physician's flag opens the episode inside Epic; CoachCare picks it up, reaches the patient and books the visit.
Piedmont's existing programs are Epic-integrated; so is this one, at the level of the discharge event, the order set and the claim.
The practices' physicians govern the protocols and every clinical decision. CoachCare's care team runs the monitoring, the outreach and the documentation under them, on one written escalation logic that applies to every program: transitional care, remote monitoring and chronic care management alike.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache, sudden swelling. CoachCare's urgent and emergent policy supersedes any client-specific preference. If the patient refuses, the practice is notified; otherwise CoachCare activates 911.
Out-of-range but not emergent findings route to the clinician or nurse the practice designates, with the readings, the symptom check and the recommended next step attached.
A retake that lands in range and a symptom check that is clean closes the loop with a chart note and nothing else. The practice's inbox is reserved for what needs a decision.
An unreachable patient is re-attempted on a schedule and the practice is notified at every decision point; a patient who stops transmitting is worked before a billing month is lost, and program discharge follows the practice's instruction, never a silent drop.
The discharge cohort is screened by ICD-10 and routed to the right device and program on an ordered hierarchy: the highest-priority qualifying diagnosis decides the device. A heart-failure discharge gets a scale and a cuff; a diabetes discharge gets a glucometer.
Verbal or written consent documented in the chart, the device set up at the office visit or shipped and activated by phone, thresholds confirmed with the practice, and the first reading checked within 48 hours.
Every enrolled patient runs two parallel loops each month: the escalation loop above, and a billing-threshold loop that tracks days of data and minutes of management so a claim is generated only when the code's requirements are met.
A 24-month forecast in two lines. The transitional care line: 398 Medicare discharges a month, half captured into a completed episode, 30% billed as high complexity. The office-based line: RPM and chronic care management for about 3,350 Medicare patients discharged in a year, an established panel of roughly 10,470 across the Conyers practices, 34 referring clinicians, one CoachCare-funded enrollment specialist at the hospital, Atlanta locality rates and the Epic integration.
| Line | Net reimb. | CoachCare fees | Net to hospital |
|---|---|---|---|
| Transitional care management (4,563 episodes) | $1,046,040 | $243,675 | $802,365 |
| RPM | $1,566,495 | $928,131 | $638,364 |
| CCM | $1,700,522 | $893,065 | $807,457 |
| Implementation, Epic integration, outreach | — | $60,222 | −$60,222 |
| Office-based programs, 24 months | $3,267,017 | $1,881,418 | $1,385,599 |
| Combined, TCM + office-based, 24 months | $4,313,057 | $2,125,093 | $2,187,964 |
| Enrollment outreach, care management and device logistics are CoachCare's expense: embedded in the fee, never a separate charge to the hospital and never deducted from its margin. | |||
Combined 24-month margin: 50.73% of net reimbursement (transitional care plus the office-based programs). The office-based programs alone run 42.41% (Year 1 41.74%, Year 2 42.89%); the transitional care line carries no platform fee, which is what lifts the combined figure.
Year 1 is $931,468 net to the hospital on $1,831,045 of combined net reimbursement (office-based $564,580 on $1,352,735; transitional care $366,888 on $478,310). Year 2 is $1,256,496 on $2,482,012 (office-based $821,018 on $1,914,282; transitional care $435,477 on $567,730). Month 1 of the office-based line is −$2,493 as the one-time setup lands ahead of the ramp; it is positive from month 2 onward.
Recurring monitoring and care-management volume over 24 months in the office-based programs, generated billing-ready inside Epic; the 4,563 transitional care claims are on top.
Blood pressure, weight and glucose, a continuous picture of the heart-failure, hypertension and diabetes cohorts between visits.
About $1.58M in acute-care cost that never gets spent, at $15,000 per admission, and that many fewer 30-day returns counted against the hospital.
About 26,958 care-team hours of monitoring, outreach and documentation in the office-based programs, plus 4,563 hours on transitional care episodes, carried by CoachCare, not by hospital staff.
Remote monitoring reaches its ceiling of 762 enrollments in month 7 and chronic care management its ceiling of 754 in month 8. From there the census holds at 1,516 active enrollments, 988 unique patients, and the terminal size is reached in year one. The binding constraint on this forecast is the size of the discharge cohort, not enrollment capacity. That is what the hospital's own discharge disposition data, the confirmed clinician roster and the chart counts by clinic all move.
| Program | Ceiling | How it is defined | Reached |
|---|---|---|---|
| RPM | 762 | 3,350 in scope × 65% eligible × 35% acceptance | Month 7 |
| CCM | 754 | 3,350 × 75% × 30% | Month 8 |
| At month 24 | 1,516 | Active program enrollments = 988 unique patients | — |
Every ceiling above is reached with one CoachCare-funded enrollment specialist placed at the hospital, working the discharge list. Without that specialist the same ceilings are reached months later and 24-month office-based net reimbursement falls to $3,089,856. The specialist cannot raise a ceiling, but reaching it in month 7 instead of later is worth $177,161 over 24 months, and it is CoachCare's payroll. A second specialist adds $100,973 more.
The forecast captures half of eligible discharges into a completed episode. At 25% capture the transitional care line is $523,020 of net reimbursement and $401,183 to the hospital over 24 months; at 75% it is $1,569,060 and $1,203,548. The relationship is linear, which is why the discharge disposition and payer mix by month is the first item on the discovery agenda.
Adjust the assumptions and watch the 24-month forecast recompute live. The office-based engine is the workbook's own enrollment model; the transitional care line is a separate episodic calculation, and the two add up at the bottom. The hospital's own discharge counts are the first thing to plug in.
CMS has proposed cutting the remote-monitoring device-supply codes for CY2027. The proposals are narrower than the headline. Here is what they do to the forecast on this page, with every code repriced at the Atlanta locality amounts the hospital's own claims would pay, on this forecast's own billing mix.
The proposals reach the remote-monitoring family only. Chronic care management moves −2.2% ($37,468 of the $1,700,522 it carries) through conversion-factor and RVU churn, and transitional care management moves −2.0% ($21,028 of $1,046,040). Neither family is a target of the rule.
Two contingencies are already in build. An unbundled arrangement, with the software platform, device logistics and program enablement priced separately, and an MSO-style arrangement in which CoachCare manages the staffing while the hospital owns the clinical program and the billing. Whichever way the final rule lands, the program does not have to be rebuilt.
CMS's ACCESS Model points at the destination: remote care paid as a risk-based per-member-per-month amount, with half of each payment withheld and reconciled against outcome attainment. Fee-for-service code cuts and that shift are the same policy argument. Pay for results rather than for device-months. A hospital already inside an MSSP ACO with heart-failure episodes starting in 2027 is on that road.
Three numbers, each smaller than the last, because each one sits on a larger base. Then the transitional care line, which barely moves. All three bars are drawn on one shared dollar scale, so the orange can be compared directly across them.
24-month net reimbursement, CY2026 final versus CY2027 proposed, every code repriced at Palmetto GBA Georgia locality 01 (Atlanta) amounts, non-facility, on this forecast's own billing mix. Enrollment, discharge capture, acceptance and mix held constant. This is the rate change alone.
Atlanta locality non-facility amounts, CY2026 final against CY2027 proposed, the same basis as the repricing above, so the code table and the bars reconcile.
| In scope: remote monitoring | ||||
|---|---|---|---|---|
| Code | What it pays for | CY2026 | CY2027 | Change |
| 99453 | Setup and patient education | $22.18 | $20.41 | −8.0% |
| 99445 | Device supply, 2–15 days | $53.00 | $42.10 | −20.6% |
| 99454 | Device supply, 16–30 days | $53.00 | $42.10 | −20.6% |
| 99457 | Treatment management, first 20 minutes | $52.58 | $50.43 | −4.1% |
| 99458 | Treatment management, each additional 20 minutes | $42.06 | $41.08 | −2.3% |
| 99470 | Treatment management, first 10 minutes | $26.46 | $21.01 | −20.6% |
| Not in scope: care management and transitional care | ||||
| 99490 | Chronic care management, first 20 minutes | $67.19 | $65.00 | −3.3% |
| 99439 | Chronic care management, each additional 20 minutes | $51.25 | $50.72 | −1.0% |
| 99495 | Transitional care management, moderate complexity, visit within 14 days | $223.60 | $218.79 | −2.2% |
| 99496 | Transitional care management, high complexity, visit within 7 days | $303.22 | $297.86 | −1.8% |
The device-supply and short-treatment codes are held to a one-year maximum reduction by section 1848(c)(7) of the Act, which phases any decrease of 20 percent or more over two years. CY2027 is the capped year; the remainder of the crosswalk lands no earlier than CY2028.
The comment period on CMS-1848-P closed September 14, 2026. The final rule publishes in early November 2026 and takes effect January 1, 2027. CoachCare is leading advocacy on the remote-monitoring provisions and will rerun this forecast against the final rates the week they publish.
CoachCare operates as the service line's engine while the practices' physicians govern protocols and every clinical decision. Full-service delivery means launch needs no new hospital headcount; the Epic build runs in parallel with onboarding, and the first transitional care episodes open on the first discharge list.
Named program lead at the hospital and at the Conyers practices; P&L and scorecard; protocol sign-off for the heart-failure, COPD, pneumonia, hypertension and diabetes pathways; the discharge-event trigger and transitional care order set built in Epic; the enrollment specialist placed with case management.
Transitional care on every captured Medicare discharge from the first week; remote monitoring set up at the 7- and 14-day visits; chronic care management from the same month through the Wellbrook and Sigman Road practices; the three-touch cadence live from the first discharge.
Remote monitoring fills in month 7 and chronic care management in month 8; the transitional care line reaches about 209 episodes a month by month 5. Monthly scorecard to the executive team; principal care management in the Piedmont Heart clinic ahead of the CY2027 heart-failure episodes; the same discharge lane extended to the sister Piedmont hospitals on the east side if the hospital chooses.
The service line on this page runs on infrastructure already proven at national scale.
Over 400 managed conditions for 500,000+ patients.
Providers running remote care programs on the CoachCare platform day to day.
Programs stood up and running in market.
Care-plan coding and billing behind more than 5 million claims.
Over 100 million vitals recorded and 4 million+ care actions enabled.
Six reasons this partnership fits Piedmont Rockdale specifically, not remote care in general.
CoachCare uses Epic's own workflows, so the hospital and the Conyers practices enroll and monitor without learning a second system. Enrollment flags and orders leave the chart, and device readings, care documentation, enrollment status and claim-ready charges come back into it. CoachCare is the only care-management application integrated with Epic that generates the claims automatically.
The care team, cellular devices, 24/7 alert triage and billing preparation are CoachCare's payroll, at a 50.73% combined margin. The hospital does not add staff to start this, and patients begin receiving services in under five days from the discharge flag.
The practices' physicians govern the protocols and every clinical decision. CoachCare's care team runs the monitoring, outreach and documentation under them, on one written escalation logic that covers transitional care, remote monitoring and chronic care alike. Claims go out under the hospital's and practices' own entities.
Transitional care management on every Medicare discharge, then RPM and chronic care management across the Conyers practices, run as one workflow on one care team. About 398 Medicare discharges a month feed the first lane, and a 10,470-patient panel feeds the second. One remote care service line covers both.
The discharge is the hand-off the hospital controls end to end, and in CY2024 no Piedmont Conyers clinician billed transitional care management. HRRP already penalizes the hospital on heart-failure and COPD readmissions. There is no vendor to unwind and no program to retire; this is built once, on the discharge the hospital already owns.
Fees are per active patient per month; there is no capital outlay and no payroll ramp. Because the forecast is set by enrollment pace, throughput is the lever. If the census does not build, CoachCare does not get paid, and the forecast, Disclosures and workbook behind this page are yours to keep either way.