Principal Care Management
What is Principal Care Management (PCM)?
The Centers for Medicare & Medicaid Services introduced Principal Care Management (PCM) services to provide comprehensive Chronic Care Management (CCM) to Traditional Medicare patients for a single, high-risk condition in 2020. PCM can be provided to patients with one complex chronic condition expected to last at least three months and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death. PCM services can last six months to one year, or until the patient's death. PCM services require 30 minutes of service before billing.
The introduction of PCM services is important as other CCM codes continue to require that patients have two or more chronic conditions. PCM involves developing a care plan that identifies a patient's treatment goals, interventions and follow-up schedule. It is important that this plan is developed with the patient and any caregivers to ensure that the plan is feasible for the patient to follow. PCM also includes regular patient monitoring, either in person or using remote patient monitoring, and coordination with other providers treating the patient's single, complex chronic condition.
Why provide PCM services to your patients?
Providers and patients alike benefit from PCM services. Previously, there was a gap in coding and payment for care management services for patients with only one chronic condition. Providers spend a significant amount of time and resources providing care management for a patient with a single high-risk disease or complex chronic condition that was not previously considered. PCM services allow providers to develop and implement a disease-specific care plan or adjusting a patient's medications on a regular basis. The goal of PCM is to stabilize a patient's condition through care management rather than siloed treatment from a primary care physician and specialist(s).
Who can provide PCM services?
In addition to physician offices, CCM services can be provided by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Critical Access Hospitals (CAHs). The following healthcare professionals can bill for PCM services:
- Physicians
- Physician Assistants
- Nurse Practitioners
- Certified Nurse Midwives
- Clinical Nurse Specialists
Only one practitioner/facility per patient may be paid for PCM services for a given calendar month. Services may be furnished by the billing healthcare professional as well as clinical staff that meet Medicare's “incident to” rules.
To initiate CCM services, the practitioner is required to complete an initial face-to-face visit, obtain verbal or written consent of the patient, and develop a comprehensive care plan in the electronic health record (EHR).
How do I identify patients who would benefit from PCM services?
Your strategy for identifying patients who are eligible should be tailored to your practice processes. Some practitioners identify patients who qualify for PCM during a regular office visit or Annual Wellness Visit (AWV). Other practitioners and practices use their EHR to identify patients that qualify for PCM prior to a patient visit.
How can I educate patients about PCM services and what to expect?
CMS requires verbal consent be obtained before beginning PCM services because not all patients who can receive PCM services may want them. Patients should be made aware of what the specific services are and what cost-sharing is associated with those services. Cost-sharing may apply if the patient has no supplemental insurance. Patients and caregivers should be provided with materials about managing their chronic condition to help them engage with their care plan.
What are the billing codes for PCM services?
PCM services are billable under five CPT codes:
- 99424: Principal care management (PCM) performed by a physician or nonphysician provider 30 minutes per calendar month.
- 99425: Additional 30 minutes per calendar month
- 99426: PCM performed by clinical staff under the direction of a physician or other qualified healthcare professional 30 minutes per calendar month
- 99427: Additional 30 minutes per calendar month
FQHCs and RHCs can use HCPCS code G0511 for PCM services.
How do I document PCM services in my electronic health record (EHR)?
Using EHR technology to document a care plan and care coordination between primary care, a care manager, and a specialist helps to ensure the patient receives timely care coordination and continuity of care. In addition, EHRs help all care team members have access to the patient's health information. EHRs should include structured recording of core patient information including demographics, problem list, medication, and allergies.
Who in my organization should I engage when designing and implementing PCM services?
Implementing PCM in your practice requires broad support, beginning with leadership and the medical staff. Successful implementation requires a cultural change and is supported by clearly defined roles and workflows for everyone on the care team. Working with coding and billing staff before implementing PCM is important for developing complete documentation and systems to bill for the service. Collaborate with health information technology staff to identify or develop how patient contacts will be captured in the EHR. Engage other members of the care team, such as pharmacists, social workers, dietitians, nurses, medical assistants, and others who will have contact with the patient.
How should I schedule staff to provide PCM services?
Practices have taken varied approaches to providing care coordination. The decision to hire new staff for PCM depends on how many patients a practice determines will likely elect PCM. First, the practice should determine how many patients are eligible for PCM. Next, the practice should determine how many of those patients will realistically elect PCM. A smaller practice may choose to assign existing staff to coordinate PCM. A larger practice may choose to hire a full-time staff member, such as a registered nurse (RN) care coordinator, to manage PCM, along with other services such as Transitional Care Management (TCM) and AWVs. PCM services can be subcontracted to case management companies, but the case management must meet “incident to” requirements and should be integrated with the care team.
PCM requires 24/7 access to care. Practices have taken varied approaches to meeting this requirement. Many practices with relationships to their local hospital use emergency department or inpatient staff to meet after-hours needs. Independent practices have chosen to contract with 24/7 call services.
Are there any special considerations for Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) billing for PCM services?
RHCs and FQHCs can bill for PCM services using G2064 and G2605 as well as G0511 for General Care Management. The payment amount for HCPCS Code G0511 is set at the average of the national non-facility Physician Fee Schedule payment rates for CCM, General BHI, and Principal Care Management (PCM).
Resources
- Medicare Program; CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule, The Federal Register
- Principal Care Management CPT Codes, HealthArc
- Chronic Care Management (CCM) Services, Noridian Healthcare Solutions
- Chronic Care Management Services, Centers for Medicare & Medicaid Services
- Care Management (CCM) Services in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Frequently Asked Questions, Centers for Medicare & Medicaid Services
- Rural Health Clinics Center, Centers for Medicare & Medicaid Services, Centers for Medicare & Medicaid Services
- Federally Qualified Health Centers (FQHC) Center, Centers for Medicare & Medicaid Services
Last Updated: 11/26/2024
Last Reviewed: 11/26/2024