Wellness Initiatives

Physician Practices
Hospital Groups
Post Acute Care

Our Goal

Our Services

Our core focus is the patient – improving quality of life through education and awareness. We believe that our wellness initiatives will enable you to grow practice profitability and support positive patient outcomes.  We hope you will join us by participating in this worthwhile effort. We are thrilled to offer a program that will focus on the well being of your most valuable asset—your patients. ​

Chronic Care Management

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions.

In addition to office visits and other face to face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff).

Behavioral Health Integration

​Behavioral health integration (BHI) care management focuses on behavioral health or psychiatric issues, in particular, whereas chronic care management as described by codes 99487, 99489, and 99490 addresses all health issues with particular focus on the multiple chronic conditions being managed by the billing practitioner.

Code G0507 represents general BHI care management services that may incorporate other models of care than that described by the other three codes for BHI.

G0507 is defined as care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional time, per calendar month and has no deductibles, coinsurance, or copayments.

Why participate in the BOCO Medical CCM Program?


Our unique offering is designed to deliver enhanced outcomes to your patients and their caregivers. Our pro-active care has delivered enormous results including 26% reduction in A1C levels in Diabetes patients and reduced unplanned admissions.


We use proven methodology to streamline and maximize patient enrollment to your CCM program.


We provide the state-of-the art capabilities and support systems to amplify the patient engagement to levels unseen in any patient portal technologies to date. We have higher than 50% of patients who login to self-report their health data.

Our Scope of Services:

  • Dynamic Care Plan shared with all your patient’s providers
  • 24/7 access to personalized care team
  • Individualized Health Record
  • Access real-time health data and monitor your enrolled patients
  • Easy-to-use web and mobile app for patients, their family, and caregivers
  • Monthly reports required by Medicare
  • Remote vitals monitoring with integration with trackers and wearable devices
  • Direct messaging for effective information exchange

The Benefits of a BOCO Medical CCM Program:

Empower your patients with virtual care and realize new and recurrent revenue stream.  Get more appointments with all patients with more pro-active monitoring & reminders for routine maintenance.
We identify and enroll eligible CCM beneficiaries from your EMR system and deliver superior patient engagement models. We guarantee complete integration of our services into your workflow and NO additional burden to your staff.

Proprietary and Patented mechanisms to engage patients to improve their health and overall satisfaction.  We manage referrals to ensure efficient in-network referrals in the most pro-active manner.

Frequently Asked Questions (FAQs):

Does CMS have a specified list of chronic conditions that meet this definition?
As long as you clearly communicate within the care plan that the chronic conditions you are treating pose a significant risk of death, acute exacerbation or de-compensation, or functional decline and will last the expected length of time, the requirement is satisfied. CMS has not specified or otherwise limited the eligible chronic conditions that meet this definition. CMS does have a reference regarding chronic conditions (http://www.ccwdata.org). However, this reference is neither an exhaustive nor definitive list.

What are the requirements needed to initiate CCM services?
Medicare requires you to furnish to the patient an Annual Wellness Visit (AWV), Initial Preventive Physical Examination (also known as a “Welcome to Medicare Visit”), or comprehensive evaluation and management (E & M) visit before billing the CCM service. Our team helps identify the patients who are eligible and assist with scheduling the appointments to maximize CCM enrollment.

What should be in a care plan?
The plan of care should typically include, but is not limited to, the following elements:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions
  • Medication management
  • Community/social services ordered
  • The individuals responsible for each intervention
  • Requirements for periodic review and, when applicable, revision of the care plan

What are the BHI Conditions?

The patient must be diagnosed and being actively treated for any of the ICD-10s
associated with the following conditions.

G0507 Conditions List:

  • Depression
  • Anxiety
  • Alcohol dependence, Intoxication, Withdrawal
  • Illicit drug use
  • Bipolar disorder
  • Schizophrenia
  • ADD
  • Autism
  • Dementia with behavioral disturbance
  • Cerebral palsy with mental retardation
  • Conversion disorder
  • Manic disorder
  • Paranoia
  • Delusional disorder
  • Suicidal behavior
  • Panic disorder
  • Obsessive-compulsive disorder
  • Non-epileptic seizures
  • Developmental delay
  • Hallucinations
  • Eating disorders
  • Sexual disorders
  • Dissociative disorders

What are CCM Scope of Services?


24-hours-a-day, 7-days-a-week access to care management services, which means providing patients with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.


Continuity of care with a designated provider or member of the care team with whom the patient is able to get successive routine appointments.


Care management for chronic conditions including:

  • Systematic assessment of patient’s medical, functional, and psycho-social needs
  • System-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management of medications


Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psycho-social, functional, and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.


Management of care transitions between and among health care providers and settings, including the following:

  • Referrals to other clinicians
  • Follow-up after a patient visit to an emergency department
  • Follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities


Coordination with home and community based clinical service providers as appropriate to support a patient’s psycho-social needs and functional deficits.


Enhanced opportunities for a patient and any relevant caregiver to communicate with the provider regarding the patient’s care through not only telephone access but also the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation methods.


Use of certified electronic health record (EHR) or other health information technology or health information exchange platform that includes an electronic care plan accessible to all providers within the practice, including those who are furnishing care outside of normal business.

Who provides services to patients?
The definition states that “clinical staff” must provide the 20 minutes to qualify. “Clinical staff,” as defined by CPT, “is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that professional service.” If the physician or other qualified health care professional (e.g. nurse practitioner or physician assistant) supplies the time, that time may also count toward the 20 minutes.

How does CCM benefit my practice?

CCM offers several benefits to your practice or organization including:

  • Generates new stream of revenue while improving your practice's reputation
  • Boosts your patient satisfaction levels to new highs by extending your reach through our services = enhanced patient retention.
  • Coaching and activity trackers measure your patient’s progress over time and improves medication and care plan adherence
  • Test results and personalized recommendations to track care management
  • Your organization will be prepared to tackle value based delivery measures required by current and future medical payers
  • Patients can participate with as little as a telephone

Does CCM Software integrate with my EMR system?
We connect with 720+ EMR systems. Our information sharing approach with EMRs avoids costly, time-consuming integration issues.