Six Mass General Brigham hospitals entered TEAM as mandatory participants on January 1, 2026 — and coronary artery bypass graft is one of five episode categories. A remote care service line is the operating layer for that 30-day window, and it pays for itself before a single episode is reconciled.
Every item below was verified against a primary CMS file or Mass General Brigham's own published information, on July 29, 2026. Nothing here is inferred.
MGH (220071), Brigham and Women's (220110), BW Faulkner (220119), Newton-Wellesley (220101), Salem / North Shore Medical Center (220035) and Wentworth-Douglass (300018) all appear on the CMS TEAM participant list as Mandatory participants, 01/01/2026–12/31/2030.
MGH, Brigham and Women's, BW Faulkner, Newton-Wellesley and Salem each carry a 5 out of 5 CMS Hospital Overall Rating. The clinical foundation is not the question — the post-discharge operating layer is.
Mass General Brigham ACO, LLC (A4641, since 2019) and Mass General Brigham ACO 2, LLC (A5932, since 01/2026) are both in the MSSP ENHANCED track — the maximum two-sided risk arrangement. Total-cost-of-care accountability is already in place.
MGH and Brigham and Women's together recorded 296 Medicare fee-for-service CABG discharges (MS-DRGs 231–236) in CMS data year 2024, plus 520 valve/major cardiothoracic and 349 other cardiothoracic cases. Adult cardiac surgery sits at these two campuses.
Mass General Brigham runs Epic enterprise-wide. CoachCare integrates directly and bi-directionally with Epic — enrollment, discrete vitals, documentation and claim generation all inside the environment your teams already use.
Suffolk County — MGH, Brigham and Women's and BW Faulkner — runs about 42% Medicare Advantage penetration, meaning a clear majority of Medicare eligibles remain in traditional fee-for-service. That FFS majority is exactly the population TEAM episodes and FFS-billable remote care codes apply to.
MGH's 30-day CABG readmission and mortality rates are both rated Better Than the National Rate, and neither MGH nor Brigham and Women's is penalized on CABG readmissions — both sit below the peer-group median. There is no CABG readmission problem here. That is exactly why the TEAM conversation is about total episode cost, not about fixing a deficit.
Mass General Brigham did not participate in BPCI-Advanced (any model year) or CJR. TEAM is the system's first mandatory bundled-payment model. There is no legacy episode-management vendor or workflow to unwind — the operating layer gets designed once, correctly.
Mass General Brigham is not a first-time remote monitoring buyer, and this proposal does not pretend otherwise. The question is not whether you can run remote care — you demonstrably can. It is whether the cardiac surgery discharge is covered by what you built.
TEAM is not a pilot and not an opt-in. It began January 1, 2026, runs through December 31, 2030, and holds the hospital financially accountable for the full cost of an episode from admission through 30 days after discharge.
The billing stack is not a collection of codes — it is a single continuous pathway that starts the day a cardiac surgery patient leaves the building and does not stop.
Contact inside two business days, medication reconciliation, and a face-to-face visit inside 7 or 14 days. TCM is the formal handoff — and it is billable at discharge, in the exact window TEAM measures.
Weight, blood pressure and pulse from day one home. Fluid overload and arrhythmia announce themselves in the data days before they announce themselves in the emergency department.
The surgical patient becomes a chronic cardiac patient. Guideline-directed medical therapy titration, heart failure surveillance and comorbidity management continue as a managed process rather than an annual event.
| Program | Codes | Clinical role in the cardiothoracic pathway |
|---|---|---|
| TCM | 99495 / 99496 | The post-cardiac-surgery handoff — contact, reconciliation, and the early follow-up visit inside the TEAM episode window. |
| RPM | 99453, 99445, 99454, 99470, 99457, 99458 | Daily physiologic data — weight, BP, pulse — from the first day home. Includes the CY2026 short-window device and monitoring codes (99445 / 99470). |
| PCM | 99426 / 99427 | Single-condition management for the dominant cardiac diagnosis where a patient does not carry two qualifying chronic conditions. |
| CCM | 99490 / 99439 | Two or more chronic conditions — near-universal in the post-CABG population, where diabetes, CKD and heart failure travel together. |
Reimbursement reflects the Massachusetts locality of the Medicare Physician Fee Schedule. Rates are locality-specific and should be confirmed against the final CY2026 schedule for each billing site.
Mass General Brigham runs Epic across the enterprise. CoachCare's integration is direct and bi-directional — built so a remote care program becomes part of the existing clinical workflow rather than a parallel one.
Enrollment flags and trigger ordering sit inside the clinical workflow. The CoachCare team enrolls qualified Medicare patients on the service line's behalf, and enrollment status is visible in Epic in real time.
Bi-directional at intake, so the monitoring program starts with the chart rather than re-collecting it.
Device readings land in the chart as discrete vitals — trendable, reportable, and usable in clinical decision support. Not PDFs.
Time, touchpoints and interventions documented to an audit-ready standard inside the record.
CoachCare is the only care-management application integrated with Epic that provides automated claims creation — removing the manual per-patient, per-month claim step entirely.
Patients begin receiving remote care services in fewer than five days from the enrollment flag.
A monitoring program that generates alerts without disciplined escalation creates work, not safety. Every reading routes through one shared escalation engine with defined thresholds, defined owners and documented outcomes.
Critical values escalate regardless of whether the patient reports symptoms. Out-of-range but non-critical readings trigger a retake and a symptom check first, so a cuff error does not become a phone call to a surgeon.
A trend means three readings at least an hour apart for blood pressure, or three within seven days for heart rate. The definition is objective, so escalation is consistent between coaches and across shifts.
No answer means voicemail plus a scheduled callback — and if the value is critical or the trend is established, escalation proceeds anyway. Silence is never read as stability.
Chest pain, new shortness of breath, stroke signs, syncope, worst-ever headache or sudden swelling trigger a 911 call with the patient still on the line. If the patient refuses, the care team routes to the clinic; if contact is lost and the presentation is emergent, CoachCare activates 911 directly.
CoachCare's urgent and emergent policy supersedes any client-specific escalation preference. This is not configurable, and it is the reason the program can be trusted with a post-surgical population.
Emergency routes to 911. Non-critical but actionable routes to a defined member of the practice team. Stable and resolved is documented as an FYI in the record. The service line sees what needs a clinician and is not buried in what does not.
Any hospitalization or ER visit in the last 60 days triggers a structured cadence: days 1–2, days 5–8, and days 12–14. That cadence maps precisely onto the first two weeks of the TEAM episode window, where readmission risk concentrates — and it is the mechanism behind the modeled hospitalizations avoided.
Every escalation documents the vital, the findings, the contact method, who was reached, the outcome and the follow-up. Continuity governance re-escalates unreachable patients on a fixed cadence, and the practice is notified at every decision point.
Modeled on the cardiothoracic surgery service line at MGH and Brigham and Women's, using Massachusetts locality reimbursement. CoachCare funds the enrollment engine, so there is no capital at risk and no negative-margin month.
| Measure | Year 1 | Year 2 | 24 months |
|---|---|---|---|
| Net reimbursement | $1,525,829 | $2,161,937 | $3,687,766 |
| CoachCare fees | $898,025 | $1,248,218 | $2,146,243 |
| Service line margin | $627,804 | $913,719 | $1,541,523 |
| Margin % | 41.1% | 42.3% | 41.8% |
A CoachCare-funded on-site enrollment specialist is included in the model at CoachCare's expense. It is embedded value in the program, not a cost deducted from the service line's margin.
In active remote care at month 24, deduped across programs.
Over 24 months — the figure that also moves the TEAM episode and the readmission measure.
Captured and trended into the record over 24 months.
Care team hours returned — about 30,357 hours over 24 months.
Confirm the cardiothoracic surgical and heart failure denominators against your own chart counts rather than CMS claims proxies, and agree the eligible cohort for year one.
Map TCM, monitoring and escalation onto the existing cardiac surgery discharge process — and specifically onto the first fourteen days, where readmission risk concentrates.
Bi-directional integration, enrollment flags in the workflow, and a CoachCare-funded on-site enrollment specialist embedded with the service line.
Prove the pathway on one cardiac surgery service, then extend the same infrastructure to the second campus and to adjacent service lines — the enrollment, device, triage and billing engine is built once and reused.
Across more than 400 managed conditions.
Committed to remote care excellence.
Successful in-market deployments.
Care plan coding and billing generated.
Physiologic readings captured to date.
Clinical interventions enabled.