Transforming Chronic Kidney Disease (CKD) Care: The Role of Remote Monitoring & Chronic Care Management

Chronic kidney disease (CKD) affects more than 37 million Americans, yet almost 90% of those with CKD do not realize they have it. Early detection, proactive management, and ongoing patient engagement are crucial for slowing disease progression and preventing complications.
With new CMS reimbursement models and advancements in remote patient monitoring (RPM) and chronic care management (CCM), healthcare providers can now access more tools than ever to improve CKD outcomes—all while enhancing practice efficiency.

This blog explores:

1. The current challenges in CKD management

2. The impact of RPM & CCM on early intervention and disease progression

3. How nephrology practices and providers can leverage this technology for better patient care

4. CMS reimbursement opportunities for CKD-related remote care

Understanding CKD & Its Challenges

The Growing Burden of Chronic Kidney Disease

• High Prevalence: Over 1 in 7 adults in the U.S. have CKD.
• High Costs: Medicare spends $87 billion annually on CKD-related care.
• Silent Progression: Many patients do not experience symptoms until late-stage kidney disease.

Challenges in CKD Management:

• Late Diagnosis: CKD often goes undetected until advanced stages, making management complicated and comprehensive.
• Patient Non-Adherence: Managing diet, medications, and comorbidities requires ongoing engagement.
• Limited Access to Nephrology Care: Rural and underserved communities face care shortages, but especially specialist shortages.
• High Readmission Rates: Many CKD patients experience frequent hospital visits due to compounding complications, particularly in comorbid patients.

How Remote Care Solutions Improve CKD Management

The Role of RPM in CKD Care

RPM enables real-time tracking of critical CKD indicators, such as:

• Blood pressure monitoring (to prevent hypertension-related kidney damage)
• Glucose levels (for diabetic CKD patients)
• Weight monitoring (to detect fluid retention and edema)
• Medication adherence tracking - most biometric readings are incredibly sensitive to patient lifestyle decisions, which display general adherence or not

RPM Benefits for CKD Patients & Providers:

• Early intervention – Providers receive real-time alerts for abnormal readings (defined by the provider).
• Improved patient engagement – Patients easily stay actively involved in their care with devices that allow seamless integration into patient’s life.
• Reduced hospitalizations – Fewer ER visits due to better symptom management, early detection, and early intervention.

The Role of CCM in CKD Care

Chronic Care Management (CCM) ensures ongoing, structured support for CKD patients by:

• Providing 24/7 access to care coordinators
• Helping with medication adherence and lifestyle modifications
• Coordinating prescription refills, specialist visits, and lab tests
• Reducing disease progression through consistent follow-ups and continuity of care

CMS Reimbursement Opportunities for CKD Remote Care

With the new APCM billing codes, nephrology practices and healthcare providers can now receive Medicare reimbursement for remote care services:

Additionally, CCM and RPM billing codes, such as CPT 99439, 99490, 99491, 99454, 99457, and 99458, provide additional revenue opportunities for nephrology practices managing CKD patients.

Case Study: RPM’s Impact on CKD Outcomes at Dallas Renal Group

Challenge:

Dallas Renal Group sought to improve blood pressure control, support patient treatment/medicine adherence, and reduce hospitalizations for CKD patients across multiple locations.

Solution:

The practice implemented an RPM program, providing real-time patient monitoring via outsourced clinicians, alerts for abnormal readings, data analytics, and proactive intervention for CKD patients.

Results:

Improved Blood Pressure Readings

Patients across locations and service areas experienced significant improvements in both systolic and diastolic blood pressure readings:

• Systolic blood pressure decreased by an average of 15.6% across all locations.
• Certain locations reported even greater reductions, ranging from 16.5% to 17.1%.
• Diastolic blood pressure showed an average improvement of 21.4%, with some locations achieving reductions as high as 24.7%.

Reduction in Patient Churn

• The practice reported improved patient retention, stating that RPM positively impacted long-term patient engagement.
• While churn reached 12.9% in August (our first month with the practice), it stabilized at lower levels in the following months.

Increased Patient Satisfaction & Compliance

• Our remote clinical staff helped patients understand the importance of daily readings and consistently engaged with their care team. They also help patients remember to take them.
• Patients reported high satisfaction with the support and accessibility provided through the program.

Cost Savings & Reduced Hospitalizations

• The RPM program is built to identify abnormal readings early, allowing for timely interventions by in-person and remote clinical teams—preventing costly hospital admissions.

Implementing RPM & CCM for CKD Care

Best Practices for Providers:

• Select the right RPM devices for CKD-related monitoring.
• Integrate remote care into existing nephrology workflows. (for example: our integration with Acumen Epic)
•  Ensure patient engagement & education on remote monitoring.
• Leverage CMS reimbursement codes for financial sustainability. We provide a comprehensive RPM & CCM platform designed to support nephrology practices and health systems in delivering high-quality, technology-driven CKD care.

Where to Go From Here

With National Kidney Month highlighting the importance of early detection and proactive CKD management, providers can now integrate RPM and CCM solutions to benefit their leaders, staff, providers, and patients.

By leveraging technology, data-driven insights, and CMS reimbursement opportunities, healthcare organizations can enhance patient outcomes, reduce ED visits, and improve practice efficiency.

Want to learn more about implementing RPM & CCM for CKD patients? Schedule a meeting today!