Chronic Kidney Disease Management

Slow CKD progression, reduce hospitalizations, and generate consistent Medicare revenue with our fully managed care program.

Chronic Kidney Disease Management requires more than the occasional checkup. With RPM & CCM Health, your primary care practice can take control of kidney care—without adding extra strain on your team. Our fully systematized CKD Care program combines Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) to deliver proactive, outcomes-driven care while generating new revenue. Below are the key benefits of our CCM program.

Key Benefits:

• Stage-based monitoring with actionable alerts
• Seamless EHR integration for streamlined workflows
• Monthly care team check-ins with comprehensive lab review

Call us at 914-420-1023 | Schedule Your Free Kidney Care Strategy Call

CKD Affects 1 in 7 Adults, But Most Don’t Know They Have It

According to CDC research, more than 37 million Americans live with Chronic Kidney Disease (CKD)—yet nearly 90% don’t even know they have it. In its early stages, CKD often progresses silently, making proactive monitoring and management essential for better outcomes.

CKD isn’t just a kidney issue—it’s closely linked to chronic conditions like hypertension, diabetes, and obesity. As these conditions progress over time, the risk of kidney failure increases—along with the cost of medications and ongoing treatment. CKD-related complications drive significant healthcare expenses, particularly among Medicare-covered populations. That’s why early intervention isn’t just smart clinically—it’s financially wise, too.

But with the right tools, your practice can shift from reactive to preventive care. With a streamlined CKD Care program, you can catch the disease in its early stages, improve patient compliance, and unlock RPM and CCM reimbursement opportunities—all without adding stress to your clinical staff.

Full-Service CKD Management for Better Outcomes

Our Chronic Kidney Disease remote monitoring program is designed to support patients at every stage of CKD—while making compliance and care coordination easier for your team. Our clinical professionals handle everything efficiently, with direct integration into your EHR for a seamless experience.

How Clinical Staff is Supported

• Routine lab tracking, including EGFR, creatinine, and BUN
  
• Ongoing blood pressure and weight monitoring through RPM
  
• Medication reviews to prevent nephrotoxic drug interactions
  
• Monthly nurse-led care plan updates
  
• Virtual nutrition consults with kidney-friendly diet planning
  
• Collaboration with nephrologists to ensure comprehensive care
  

Improving the Patient Experience

• RPM devices for home monitoring (BP cuff, cellular scale)
  
• Custom-branded patient portals to boost engagement
  
• Dietitian-led virtual education sessions
  
• Follow-up alerts for lab work and medication refills
  
• Assistance with transportation, labs, and scheduling 24/7

With clinical insights and real-time data collection, your practice can deliver the kind of care that keeps your CKD patient engagement program effective—and your patients out of the hospital. Early detection and consistent monitoring are critical. Your practice can lead this transformation while boosting revenue through CCM and RPM.

CKD Management CPT Codes for Reimbursable Kidney Care

Is This Program Right for Your Practice?

The Medicare CKD monitoring program is built to support a wide range of healthcare providers. If your practice cares for patients with chronic conditions, you’re in the perfect position to offer remote monitoring and care coordination for patients with chronic kidney disease.

Here are the types of providers who are ideally suited for this role:

• Primary Care Providers
  
• Internal Medicine Practices
  
• Geriatric Clinics
  
• Nephrology Groups
  
• Community Health Centers

How Our CKD Program Works for You and Your Patients

Managing CKD stages doesn’t have to be complicated. Our streamlined program is designed with both patients and clinical staff in mind—every step of the way. Here’s how it can work for you and your patients:

1. Identify Eligible Patients

Identify patients in stages 1–4 of CKD directly through your existing EHR system.

2. Seamless Enrollment through Your EHR System

Enroll patients directly through your EHR. Our platform integrates seamlessly with your existing system—no added stress, just a hassle-free experience.

3. Remote Monitoring Devices Shipped to Patients

We provide home monitoring tools—like a blood pressure cuff and digital scale—so patients can start tracking key health metrics from day one.

4. Ongoing Clinical Support
Patients receive monthly check-ins from a dedicated nurse, along with ongoing support from a licensed dietitian.

5. Coordinated Labs & Medications
We help coordinate lab scheduling, track results, and manage medications to minimize gaps in care.

6. Real-Time Alerts & Reporting
Receive timely clinical updates, actionable alerts, and detailed reports—while ensuring accurate billing and documentation.

Why Partner With RPM & CCM Health for Kidney Care

Our dedicated kidney care team nurses help drive better outcomes and strengthen your practice’s performance—with a program built around your needs.

Track eGFR Trends for Early Intervention
Quickly identify declining kidney function and take preventive steps to slow disease progression.

Reduce Hospitalizations and ER Visits
Continuous monitoring and coordinated care help prevent avoidable complications and reduce costly interventions.

Deliver Personalized Care, Without Adding to Staff Workload

Our clinical team engages your patients with monthly touchpoints—giving your practice more time to focus on what matters most.

Stay Compliant and Fully Documented

We take care of reporting, charting, and billing compliance—so you can focus on patient care, not paperwork.

Increase Medicare Revenue

You may be eligible to receive monthly reimbursements for each enrolled CKD patient under Medicare’s RPM and CCM billing models—while improving their long-term health outcomes.

CKD Patient Story: Early Intervention Saved a Hospitalization

One patient enrolled in our CCM for kidney care program—let’s call him Patient X—was approaching a critical point. Daily home monitoring flagged a subtle but steady rise in both blood pressure and weight. Our nephrology support service provider was alerted, prompting a timely medication adjustment. Thanks to early detection and intervention, the patient avoided serious complications. Dialysis was no longer an immediate concern—and that’s the power of proactive kidney care.

CKD Management FAQS

Can you work with my patient’s nephrologist?

Yes—we work alongside both primary care providers and specialists to deliver a fully coordinated approach to kidney care. Our team complements your nephrologist’s expertise; we don’t replace it.

What devices are used for kidney care monitoring?
We equip patients with easy-to-use, cellular-enabled devices—such as blood pressure cuffs and digital weight scales.

Is this program covered by Medicare?
Yes. Our CKD program is fully aligned with Medicare’s RPM and CCM billing frameworks. We manage all documentation and coding to support your reimbursement eligibility—so you don’t have to.

How does your team coordinate labs and prescriptions?
We assist with lab test scheduling and results tracking, and we notify you when medication adjustments may be needed. All information is securely shared with your team through your EHR.

Start Building a Stronger CKD Management Program

Help your patients avoid progression to dialysis—while improving your practice’s efficiency and revenue—by partnering with RPM & CCM Health.

Take the first step now!

Take the first step today.Call: 914-420-1023
Download: Medicare Billing Codes for CKD (PDF)
Schedule Your Free Kidney Care Strategy Call