Six Medicare programs, run end-to-end by a pharmacist team.
Each program maps to a CMS billing code your practice already qualifies for. Torch handles the staffing, calls, time-tracking, documentation, and claims packaging. Clinical authority stays with your supervising provider throughout.
Chronic Care Management CCM
Monthly non-face-to-face care coordination for patients with two or more chronic conditions expected to last at least 12 months. The backbone of between-visit care for primary care panels.
Who's eligible
Medicare beneficiaries with 2+ chronic conditions (HTN, diabetes, CHF, COPD, CKD, etc.) expected to persist 12+ months.
What Torch does monthly
- Initiates the monthly call and documents the clinical time
- Reviews medications: adherence, refills, interactions, dose appropriateness
- Updates the comprehensive care plan in your EHR
- Surfaces care-gap closures (A1c, BP, immunizations) to your team
- Escalates anything clinical to the supervising provider same-day
What your practice does
- Identifies the supervising provider for billing
- Reviews any flagged patients during the week's huddle
- Signs off on the monthly claim package
Remote Patient Monitoring RPM
Device-driven monitoring of physiologic data (BP cuffs, glucometers, scales, pulse oximeters) with a pharmacist reviewing readings and intervening when trends drift.
Who's eligible
Medicare patients with a condition that justifies physiologic monitoring. We ship cellular-connected devices, so there's no Wi-Fi setup on the patient's end.
What Torch does monthly
- Procures and ships the device, registers it under your patient's account
- Captures the monthly reading threshold CMS requires
- Reviews trends weekly; intervenes on out-of-range values
- Logs the clinical management time per month
- Returns adherence and trend data to your EHR
Device options
- BP cuff (HTN, CKD, CHF)
- Glucometer (insulin-managed type 2 diabetes)
- Scale (CHF dry-weight monitoring)
- Pulse oximeter (COPD, post-discharge)
Advanced Primary Care Management APCM
The 2025 CMS bundle. A stratified monthly payment per patient based on chronic burden and dual-eligible status. Replaces time-based CCM minutes with attribution-based management.
Three tiers
G0556 for one chronic condition · G0557 for two or more · G0558 for two or more plus dual-eligible status.
Why APCM matters
- No time-tracking burden, pays on attribution, not minutes
- Bundles coordination, gap closure, and patient communication
- Aligns cleanly with value-based contracts and Medicare Advantage risk
- Built for complex and dual-eligible panels
What Torch does monthly
- Stratifies the panel by tier and confirms attribution
- Delivers a defined set of coordination touches per tier
- Manages the 24/7 access requirement (we take the call)
- Tracks the population-level quality metrics CMS requires
Transitions of Care TCM
The first 30 days after a hospital or SNF discharge, when medication errors are most common and readmission risk is highest. A pharmacist call within two business days catches the worst of it.
Who's eligible
Any patient discharged from an inpatient, observation, SNF, or psychiatric facility back to a community setting under your practice's care.
The 30-day arc
- Day 1-2: Interactive contact (Torch call); discharge med reconciliation
- Day 1-7: Patient sees the supervising provider for the in-person follow-up
- Day 7-30: Adherence checks, symptom monitoring, escalation if needed
- Day 30: Hand-off to CCM or APCM going forward
What Torch catches
- Duplicate or contraindicated discharge prescriptions
- Patients filling old meds plus new (major interaction risk)
- Symptoms in the danger window: chest pain, SOB, edema, falls
- Patients without a confirmed PCP follow-up appointment
Behavioral Health Integration BHI
Behavioral health folded into primary care. A behavioral health care manager tracks symptoms month to month with validated measures, and a psychiatric consultant advises your team, so depression and anxiety get managed alongside the rest of the patient's care.
Who's eligible
Medicare patients with a behavioral health condition, commonly depression or anxiety, being managed in your primary care practice.
What Torch does monthly
- Tracks symptoms with validated tools such as the PHQ-9 and GAD-7
- Keeps a registry and reviews patients who are not improving
- Brings a psychiatric consultant's input back to your provider
- Coordinates medication changes and follow-up
- Logs the clinical time and prepares the claim
Two ways to bill it
- General BHI (99484) for integrated behavioral health management
- Collaborative Care (99492, 99493, 99494) when a psychiatric consultant is formally involved
- Billed monthly under your supervising provider
Annual Wellness Visit AWV
The once-yearly Medicare visit most practices know they should be doing but can't staff the prep for. We pre-fill the HRA, surface the care gaps, and hand the visit to your provider ready to sign.
Who's eligible
Every Medicare beneficiary, once per 12 months. G0438 is the first ever; G0439 is each subsequent year.
The Torch pre-visit packet
- Completed Health Risk Assessment (HRA) over the phone
- Schedule of all preventive care due in the next 12 months
- Cognitive screen (MMSE / Mini-Cog) when indicated
- ADL / IADL review and fall-risk score
- Personalized prevention plan, ready for provider sign-off
What this unlocks
- Care-gap closure attached to a billable visit
- Identifies CCM / RPM / APCM enrollment candidates
- Major HEDIS / MIPS measure attribution in one visit
- Sets the patient's narrative for the rest of the year
How the six programs differ.
Cadence, time requirements, and best fit across the six programs. Your panel composition determines where to start.
| Program | Chronic CareCCM | Remote MonitoringRPM | Adv. Primary CareAPCM | TransitionsTCM | Behavioral HealthBHI | Annual WellnessAWV |
|---|---|---|---|---|---|---|
| Billing code | 99490 | 99457 | G0556 | 99495 | 99484 | G0438 |
| Cadence | Monthly | Monthly | Monthly | Once per discharge | Monthly | Annually |
| Time | 20 min | 20 min | None | None | 20 min | ~30 min |
| Best fit | Multi-condition Medicare patients | BP, glucose, weight monitoring | Complex or dual-eligible panels | Post-discharge first 30 days | Depression and anxiety in primary care | Every Medicare patient, yearly |
We're on your time.
Our starting point is the program that fits your panel most naturally, typically CCM or RPM, with the rest added at a pace your team sets.