CMS reimburses for Principal Care Management (PCM) services provided to beneficiaries with a single chronic condition needing to stabilize that condition following exacerbation or hospitalization. Unlike CCM, which requires a minimum of two conditions and the management of total patient care, PCM focuses on disease-specific care. The qualifying condition for reporting PCM codes would be a patient with one serious chronic condition, typically expected to last at least three months and includes establishing, implementing, revising or monitoring a care plan specific to that disease. While CCM is typically provided primarily by primary care providers, PCM typically is furnished by specialists or primary care providers.
PCM is intended to provide additional care to patients with a single chronic condition or to allow a provider to treat a patient with multiple chronic conditions by focusing solely on only one of those chronic conditions causing the most problems. CMS added PCM back in 2020 to allow for this type of management and reimbursement, and recently expanded the program. It was created to “fill in the gaps” as many practices do see patients with only one chronic condition, but that would benefit greatly from more focused care and management on that one condition. Billing for PCM requires 30 minutes of care management services per month, as opposed to 20 minutes for CCM. New for 2022, CMS added add-on codes for each additional 30 minutes of PCM time as well. As part of this 2022 PCM expansion, CMS also has renamed some of the previous CPT codes. PCM services furnished by clinical staff under general supervision are now billed using CPT code 99426 (previously G0265) for the initial 30 minutes, and 99427 for each additional 30 minutes. Services furnished directly by a practitioner (physician, NPP) are now billed using 99424 (previously G0264) for the initial 30 minutes, and 99425 for each additional 30 minutes. Expansion of the program shows an investment by CMS in all forms of PCM and CCM.
Practitioners billing for PCM must document in the patient’s record ongoing communication and care coordination between all practitioners providing care to the beneficiary. And providers cannot bill for interprofessional consultations or other care management services (excluding RPM) for the same beneficiary for the same time period as PCM. Otherwise, the same requirements apply to CCM and PCM.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) bill for CCM or PCM services performed by clinical staff under HSPCS G0511. An RHC/FQHC can bill only one unit of G0511 per beneficiary per month, regardless of time spent on PCM or CCM for the patient.
Benefits of PCM
According to CDC reports, 6 in 10 people across America have one chronic disease. PCM was created to fill in the gaps for the potential millions of Medicare beneficiaries with only one, not two or more, serious chronic conditions that still require management and support. The benefits of PCMs are very similar to CCM, and are becoming an integral part of primary care management – resulting in better health outcomes for patients and reducing overall healthcare costs.
One of the primary goals of PCM is to address a patient’s chronic condition as quickly as possible, stabilizing it so overall care can be returned to the patient’s primary care physician. Long-term, this stabilizes and improves care, as well as reduces costs. The benefit of addressing one complicating chronic condition when it arises is that it greatly reduces the chances of a new, second condition arising. A benefit of all of the various P/CCM programs is that patients receive attention and focus from their health care providers – improving care, building patient trust and satisfaction, which improves patient engagement – all of which improves health outcomes. PCMs reduce health care costs, while increasing reimbursement for providers providing PCM.
Like CCMs, PCMs provide support to patients to improve their health status and have greater connection and support to the practice. They provide better managed care, and are proven to improve quality of care and health outcomes. In addition, PCM programs provide better tracking of and support to patients, which increases the quality and efficiency of care and brings down costs for providers and the health system overall.
- Quality of Care
- Efficiency of Care
- Effectiveness of Care
- Stabilization of Care
- Patient Engagement
- Patient Satisfaction
- Revenue & Reimbursement
- Costs of (Chronic) Care