CMS has named 9 MarinHealth heart-failure clinicians in the Ambulatory Specialty Model, and Medicare already pays for the care between visits. Remote monitoring and principal care management for the Medicare cardiology panel, with transitional care after each discharge, can be billed under the clinicians’ own NPIs and run by a CoachCare care team inside the Epic record the clinics and hospital share.
Heart failure and hypertension are managed in the weeks between appointments. Four changes in how Medicare pays for and measures that time are arriving together at MarinHealth: two of them are mandatory models with the clinicians’ and the hospital’s own names on them, and two are codes in the Medicare fee schedule that pay for that work today.
CMS has proposed repricing the remote-monitoring device-supply codes for 2027. The headline cut is large. What it does to a service line is smaller, because device supply is only part of a monitoring month and monitoring is only part of the line. Repriced on this forecast’s own billing mix at the Marin County locality, with enrollment held constant, the change carries through to 24-month contribution margin as shown here.
| Code | What it pays for | CY2026 | CY2027 proposed | Change |
|---|
MarinHealth Cardiovascular Medicine is the cardiology group of MarinHealth Medical Center in Greenbrae. Twenty-two cardiologists and four physician assistants see patients in Larkspur, Novato, Petaluma and Sonoma, and 20 of the cardiologists practise from the Larkspur clinic. The Medicare panel is about 12,200 patients, averaging 78 years old in traditional Medicare with an average CMS risk score of 1.41, and one patient in three carries heart failure. The clinics and the hospital share one Epic record.
An older, high-risk Medicare panel, average age 78, where hypertension is near-universal, atrial fibrillation reaches more than four patients in ten and heart failure one in three.
32% of the traditional-Medicare panel carries 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 out of the hospital.
At least 75% of the traditional-Medicare panel has hypertension, and 50% has ischemic heart disease. Home readings give the cardiologist a real average to titrate against, and they are the readings a renal denervation patient is followed on.
44% have atrial fibrillation, 29% chronic kidney disease and 23% 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 a building, a procedure or a shared record. Click through the years. The next step adds what none of them covers: daily readings and a care team between visits.
Each part of the heart program touches a patient at one moment: a clinic visit, an echo, a device check, a procedure, a discharge from MarinHealth Medical Center. 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 program to see what changes.
Two mandatory Medicare models now reach MarinHealth’s cardiology work. TEAM has made MarinHealth Medical Center accountable for spending around each coronary bypass since January 2026. The Ambulatory Specialty Model makes 9 of the group’s heart-failure clinicians individually accountable for heart-failure cost and quality from January 2027. Both are decided in the weeks after a visit or a discharge, which is where a remote care service line works.
Nine MarinHealth heart-failure clinicians are named on CMS’s final CY2027 participant list for the Ambulatory Specialty Model, billing under the Regents of the University of California (UCSF). Participation is mandatory for the clinicians CMS names. Each named clinician carries a personal score, and the payment adjustment reaches every Part B professional service that clinician bills, not only heart-failure care.
| Performance year | Reported | Paid | Range |
|---|---|---|---|
| CY2027 | 2028 | 2029 | ±9% |
| CY2028 | 2029 | 2030 | ±9% |
| CY2029 | 2030 | 2031 | ±10% |
| CY2030 | 2031 | 2032 | ±11% |
| CY2031 | 2032 | 2033 | ±12% |
Quality measures need twelve months of CY2027 data. Workflow that is not running on January 1, 2027 cannot be added to that year’s numbers later.
Named clinicians leave MIPS for each year they are in ASM. Medicare Advantage patients are excluded from the measures.
| Component | Weight | What remote care does | Effect |
|---|---|---|---|
| Controlling high blood pressureQ236 | Quality, 1 of 5 | A cellular cuff produces the home readings the measure is built from, on a schedule the cardiologist sets. | Direct |
| Functional status assessment for heart failureQ377 | Quality, 1 of 5 | The monthly principal care management call is where a standardized assessment gets done and documented in Epic. | Direct |
| Beta-blocker, and ACE inhibitor, ARB or ARNI, for reduced ejection fractionQ008 · Q005 | Quality, 2 of 5 | Home heart rate and blood pressure show when the next dose step is safe, and the care manager catches the patient who stopped a drug. | Supporting |
| Acute cardiovascular admissionsQ492, from claims | Quality, 1 of 5 | A weight gain caught on day three becomes a diuretic change by phone instead of an admission. | Mechanism |
| Heart-failure episode costfrom claims | Cost, the whole 50% | Avoided admissions are the largest lever. The program’s own billing for heart-failure patients also counts inside the episode, so it has to be earned back in avoided hospital use. | Both ways |
| Connecting to primary care; collaborative care arrangementIA-1 · IA-2 | 0 to −20 | Confirming each patient has a primary-care physician, sending the visit summary back, and sharing one care plan are the service line’s routine work. | Direct |
| Promoting Interoperability | 0 to −10 | None. This category belongs to the certified record and the practice. | No effect |
A heart-failure episode attaches to each clinician who billed at least 30% of its trigger and confirming codes. Principal care management (99426) and transitional care (99495, 99496) are on CMS’s heart-failure trigger list, so billing them puts the episode with the cardiologist who manages the patient.
The remote-monitoring codes are not heart-failure triggers, so they do not open an episode or count toward the 30% line. Monitoring billed with a heart-failure diagnosis still counts as episode cost, and it pays for itself on the cost measure only when admissions fall.
An admission that does not happen lowers the episode cost and the admission measure in the same year. Separately, the service line earns its contribution margin under the fee schedule whether or not the score moves.
MarinHealth Medical Center (CCN 050360) has been a mandatory participant in Medicare’s Transforming Episode Accountability Model since January 1, 2026, through 2030. For heart care the TEAM episode is coronary artery bypass: the surgical stay plus the 30 days after discharge, with all Medicare Part A and B spending in that window reconciled against a target price and adjusted for quality. MarinHealth has done its own bypass surgery since its cardiothoracic program opened in May 2025, so every one of these episodes now runs through the group’s patients.
Flagged in Epic before the patient leaves. Scale and cuff ordered to the home.
Contact within two business days and medication reconciliation, the TCM workflow MarinHealth already runs.
Weight, blood pressure and symptoms from day two; 99445 and 99470 bill the short first month.
Patients who need it stay on monitoring and principal care management past the episode.
TEAM counts every Medicare dollar in the 30 days after a bypass discharge, so a readmission, an emergency visit or a stay in a skilled nursing facility all land in the episode. MarinHealth Medical Center’s 30-day bypass readmission rate is 10.5%, no different from the national rate, and in FY2026 Medicare’s readmission program flagged bypass, with COPD, in a 0.02% payment adjustment. A call within two business days and readings from day two are the levers the episode rewards.
MarinHealth Medical Center holds CMS’s 5-star overall rating. In Medicare’s FY2026 readmission payment file its heart-failure ratio runs better than its peer group’s median, and on Care Compare its 30-day heart-failure readmission rate, 22.0% across 427 patients, is no different from the national rate. Heart failure is the hospital’s largest readmission cohort. Bringing that rate below average is where the cardiology group can add to a five-star record, and it is the same work that drives the ASM score.
MarinHealth’s cardiologists and physician assistants set the protocols and own every clinical decision. CoachCare staffs and runs the program. Everything runs through the Epic record the clinics and MarinHealth Medical Center already share, from the first flag on a patient’s chart to the claim at month end. The program starts with heart failure in Larkspur and extends to the other clinics on the same record.
The program starts with the panel, not a referral pad. Epic already holds the diagnoses, ejection fractions, vitals, labs, medications and every MarinHealth Medical Center admission. Patients with heart failure, uncontrolled hypertension, atrial fibrillation or a recent discharge are flagged on criteria MarinHealth’s cardiologists set, so the right patients surface at a follow-up visit, after an echo, at discharge or on an outreach list.
Example criteria. MarinHealth’s cardiologists set and own the flag logic for each condition.
Patients enter at a clinic visit, after a test or procedure, or after a stay at MarinHealth Medical Center. Each way leads into the same monthly loop: clinic visits, care management and physiologic monitoring, each one informing the next.
Flagged in Epic when the patient leaves MarinHealth Medical Center. Scale and cuff ordered to the home.
Contact within two business days, medication reconciliation, a cardiology visit in 7–14 days.
TCM 99495 · 99496Readings start right away. The short-month device code covers the first partial month.
99453 · 99445 · 99426Clinic visits ↻ care management ↻ physiologic monitoring.
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 · 99426Clinic visits ↻ care management ↻ physiologic monitoring.
The cardiologist orders from the chart, or a CoachCare enrollment specialist working in the clinic 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 Epic to the first billable day of service. Enrollment status is visible in the chart the whole way through, at every clinic.
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 MarinHealth designates, in Epic, 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 clinic. A critical reading on its own goes to the clinic. This cannot be configured away.
At month end, three things come out of the program: clean claims in Epic, an operational report for the service line’s leadership, and a clinical outcomes report for the physicians.
CoachCare is the only care-management application integrated with Epic that creates claims automatically. No one builds a claim by hand, patient by patient, month by month.
A monthly scorecard for the service line. Sample below at the modeled month-12 census.
MarinHealth Medical Center and the cardiology clinics have shared one Epic record since August 2022, on APeX, UCSF Health’s Epic, with patients on MyChart. CoachCare integrates directly and in both directions with Epic, using its built-in workflows, so the program lives in the chart the cardiologists already use. The integration is built once for Larkspur and serves every clinic on the same record after that.
Enrollment flags and orders by service and device inside the clinical workflow. Enrollment status shows in Epic as it changes.
Problems, medications and history move between Epic and the care team at intake, so no one re-keys a chart.
Weight, blood pressure and heart rate land in the chart as discrete vitals, not attached PDFs, ready for trending and quality reporting.
Care-plan updates, time and outreach are documented in the record every month, audit-ready.
When a code’s requirements are met, the claim is built for the billing team to reconcile and submit.
Because MarinHealth Medical Center and the clinics share the record, a heart-failure or bypass discharge is visible to the care team the day it happens. The flag, the transitional-care call, the readings and the follow-up visit all sit in the same chart, and patients see their results in the MyChart they already use.
The interfaces, worklists and routing are scoped with MarinHealth before the first patient enrolls in Larkspur. Novato, Petaluma and Sonoma join the same build, with no second integration project.
CoachCare Epic integration overview (PDF)A 24-month forecast for a MarinHealth remote care service line: remote monitoring and principal care management across the Medicare cardiology panel at CY2026 Medicare rates for Marin County, with the growth in transitional care shown beside it, 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-led 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.
The five heart-failure measures CMS scores for the 9 named clinicians from 2027 depend on work this program does every month. The rest of the group stays in MIPS, where blood-pressure control and the heart-failure prescribing measures count the same way. Select a measure to see how.
Watching the panel every day tells the practice who needs to be seen now, whoever is next on the schedule. Patients surface from their home readings before they come in sicker.
MarinHealth cardiologists billed about 1,830 initial hospital visits for traditional-Medicare patients in CY2024, and transitional care management for about 330 patients after discharge. The 30 days after a discharge decide whether a patient comes back. Remote monitoring and principal care management carry the patient past them, and past the end of a bypass episode at day 30.
Flagged in Epic 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.
Weight, blood pressure and symptoms through the 30 days of the hospital’s bypass episode, with a call when something changes.
Blood pressure, heart rate and weight after a transcatheter valve or left atrial appendage closure, until the first follow-up.
Rate and blood pressure after a cardioversion, an ablation or a new rate-control agent.
Every code the service line can bill, at CY2026 Medicare rates for Marin County. Build a patient-month to see what one patient is worth.
CY2026 Medicare Physician Fee Schedule, non-facility, California locality 52, San Francisco-Oakland-Berkeley (Marin County), Noridian JE, MAC 01112. 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, and transitional care bills once per qualifying discharge.
The forecast has two parts. The recurring line is remote monitoring and principal care management across the panel. Transitional care is a smaller, separate line: the growth in discharges that reach a TCM visit on top of the roughly 330 patients a year MarinHealth already bills. Select a line to redraw the charts.
| Service line | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Unique patients, end of period | 937 | 2,139 | 2,139 |
| Contribution margin, recurring line (RPM + PCM) | $329,077 | $1,383,378 | $1,712,455 |
| Contribution margin, transitional care growth | $12,774 | $20,598 | $33,372 |
| Combined contribution margin | $341,851 | $1,403,976 | $1,745,827 |
| Contribution margin runs −$5,178 in month 1 while the program ramps; positive from month 2. Transitional care growth adds nothing until month 4, when capture passes today’s level. | |||
Change the assumptions and the 24-month forecast for the recurring line recalculates. Start from the whole network or from Larkspur alone, or move the sliders yourself. MarinHealth’s own Medicare chart count by payer is the first thing to plug in, and the enrollment specialist slider shows how much onboarding 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.
MarinHealth’s cardiologists, 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, plus about 150 hours of added transitional care.
Hired, trained and managed by CoachCare. MarinHealth would otherwise need to recruit and keep them.
The enrollment specialist working in the clinics and device logistics are CoachCare’s expense.
Direct, two-way integration with the Epic record MarinHealth Medical Center and the clinics share. Physicians never leave the chart, and supporting documents (evidence of care, vitals and care plans) are attached to the patient’s chart every month.
Epic integration overviewThe staff, protocols and Epic workflow built for remote monitoring and principal care management can take on the next programs MarinHealth’s patients qualify for, without a second hiring plan.
MarinHealth clinicians already billed transitional care management for about 330 traditional-Medicare patients in CY2024, across 11 clinicians. The care team can make the two-business-day call after more cardiac discharges from MarinHealth Medical Center, so more of the follow-up visits the group already schedules qualify, and each one starts the patient on monitoring. The forecast counts only discharges above today’s level: about 150 added episodes over 24 months.
Patients scheduled for a transcatheter valve, a left atrial appendage closure, a stent or an ablation 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. Patients treated with renal denervation are followed on the same home cuff.
The device clinic already follows about 1,200 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 Epic chart.
Six reasons this partnership fits MarinHealth’s cardiology group specifically, not remote care in general.
The device clinic already reads remote transmissions for about 1,200 patients, cardiac rehab sees more than a thousand a year, and transitional care already runs after discharge for about 330. Remote monitoring and principal care management apply the same between-visit discipline to blood pressure, weight and the heart-failure care plan.
One care team, one set of protocols and one Epic workflow serve both mandatory models: transitional care and early monitoring for the 30 days of the hospital’s bypass episodes, and home readings and principal care management for the 9 named clinicians’ heart-failure measures, plus the primary-care summary the collaborative care arrangement calls for. MarinHealth builds it once.
Built on Epic’s own workflows, in the record MarinHealth Medical Center and the clinics share. Readings, documentation and claims live in the chart, and the integration built for Larkspur serves every clinic.
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. Cardiologists set the protocols and make every clinical decision.
MarinHealth’s traditional-Medicare patients average 78. 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 MarinHealth’s Medicare chart count by payer, agree on the heart-failure flag criteria for a Larkspur start, map how today’s transitional-care calls after MarinHealth Medical Center discharges hand patients on to monitoring, and scope the Epic build before the first patient enrolls.
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