REIMBURSEMENT & REVENUE ENABLEMENT

Care is happening. Revenue can leak between the work and the claim.

PrimeVital helps identify where clinically appropriate work can be structured into a covered program—then connects eligibility, documentation, coding, billing, and follow-up into one defensible workflow.

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THE WORK-TO-CLAIM GAP

Doing useful work is not the same as billing a covered service.

The opportunity is not to bill more indiscriminately. It is to find work that already aligns—or can appropriately align—with a recognized care pathway and make every required step reliable.

Telehealth is happening

The visit is completed, but recurring care needs, consent, time, and a suitable longitudinal program are not evaluated.

What PrimeVital evaluatesReview whether the patient also needs RPM, CCM, PCM, BHI, APCM, or another appropriate pathway—without rebilling the same work.

Pain follow-up is happening

Medication review, function, adherence, treatment response, and care-plan work may remain scattered across calls and notes.

What PrimeVital evaluatesEvaluate RTM, CCM, PCM, or the Medicare chronic-pain bundle based on the condition, practitioner, treatment, and distinct requirements.

Care coordination is happening

Staff make calls, reconcile needs, and coordinate services, but eligibility, consent, a maintained plan, and attributable time may be missing.

What PrimeVital evaluatesBuild a defined CCM, PCM, BHI, PIN, or APCM workflow with clear ownership and non-duplicated evidence.

Post-discharge calls are happening

Outreach occurs, but discharge notification, contact timing, medication reconciliation, decision-making, or the required visit is unreliable.

What PrimeVital evaluatesCreate a TCM handoff that starts at discharge and can transition eligible patients into longer-term monitoring or care management.

A COMPLIANT REVENUE PATHWAY

Seven gates between patient need and payment.

Select a gate to see the evidence it requires and the risk created when it is skipped.

Evidence needed

Diagnosis, risk, clinical need, and a program that is appropriate for the patient.

Risk if the gate is skipped

Starting with a code instead of a medically appropriate patient pathway.

No automatic billing promises. Not every phone call, telehealth visit, device reading, or medication discussion is separately billable. Medical necessity, code requirements, payer policy, provider eligibility, supervision, timing, and non-duplication rules govern each claim.

WHO MAY PAY

“Covered” is a patient-and-plan question, not a website claim.

PayerWhat it meansWhat must be verified

Original MedicareNational program rules with code-level requirements under the Physician Fee Schedule or Part D, depending on the service.Verify beneficiary eligibility, provider type, service requirements, frequency, exclusions, cost sharing, and local payment.

Medicare AdvantagePlans generally cover Medicare benefits but may apply plan-specific authorization, network, documentation, and claim rules.Verify benefits and operational requirements with the member’s exact plan before enrollment or billing.

MedicaidCoverage and payment vary substantially by state and delivery system.Confirm the state program, managed-care plan, provider enrollment, eligible codes, and telehealth or monitoring policy.

Commercial plansCoverage is driven by payer policy and the provider contract.Check benefits, medical policy, authorization, frequency, patient responsibility, and contracted rates.

CODE-FAMILY ORIENTATION

Know the pathway before discussing the payment.

These representative code families help visitors understand how the programs are structured. They are not a fee schedule, coding recommendation, or confirmation that a service may be billed for a particular patient.

ProgramRepresentative code familyWhat it generally organizes

RPM99453, 99454, 99457, 99458, 99091Setup, device/data supply, and treatment-management components; current data-day and interaction rules vary by code.

RTM98975–98981; 98979, 98984, 98985 added for 2026Setup, device-supply, and treatment-management services for qualifying therapeutic data and practitioner types.

CCM99490, 99439, 99487, 99489, 99491, 99437Non-complex, complex, and practitioner-provided chronic-care management families.

PCM99424–99427Monthly disease-specific management for one qualifying high-risk chronic condition.

TCM99495, 99496Thirty-day transition services distinguished by medical-decision-making and required follow-up timing.

BHI / CoCM99484, 99492–99494, G2214 and applicable add-onsGeneral behavioral-health integration and psychiatric collaborative-care pathways have different team and time requirements.

APCMG0556–G0558Monthly, non-time-based advanced-primary-care levels based on patient complexity.

PING0023, G0024, G0140, G0146Principal illness navigation and behavioral-health peer-support navigation services.

Chronic PainG3002, G3003Monthly chronic-pain management and treatment bundle plus qualifying additional time.

MTMPart D plan programMTM eligibility, delivery, documentation, and payment are established through the beneficiary’s Part D plan rather than one universal PFS pathway.

CPT and HCPCS code sets, descriptors, edits, payer policies, and payment rules change. Verify the current year’s official CMS and payer guidance and consult qualified coding resources before billing.

WHERE PRIMEVITAL ADDS VALUE

One team connects program operations to revenue-cycle execution.

Opportunity discovery

Analyze patient mix, current outreach, payer mix, program fit, and operational readiness.

Workflow design

Define enrollment, consent, devices, outreach, escalation, time capture, and documentation standards.

Claim readiness

Support eligibility, coding workflow, documentation quality, charge capture, and handoff to billing.

Revenue follow-through

Track claims, payments, denials, AR, and the operational causes that prevent repeatable collection.

This content is general operational information and is not legal, coding, billing, or reimbursement advice. Policies and payment change. Provider organizations should validate current CMS guidance, payer policy, contracts, state law, and professional coding advice before billing.

REVENUE OPPORTUNITY REVIEW

Keep the page context. Start the assessment when you are ready.

We will review care already being delivered, payer mix, documentation, charge capture, denials, AR, and the operational gaps that may be suppressing collectible revenue.

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DESIGN A PRACTICAL STARTING POINT

Tell us where the workflow is breaking. We’ll show you where to begin.

Choose how to connect

Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com