Principal care management (PCM) is a relatively new model of care that reimburses providers for treating patients who have a chronic condition. Although it has similarities with other important care models like chronic care management (CCM) and transitional care management (TCM), PCM is a separate model of reimbursement that providers should know and understand.

Another important element of principal care management is that it’s quickly evolving. The Centers for Medicare & Medicaid Services (CMS) introduced the first reimbursement codes in 2020. These codes, G2064 and G2065, were not CPT® codes, but HCPCS (Healthcare Common Procedure Coding System) codes, designed by CMS to supplement “products, supplies, and services not included in CPT.”

Two years later, in 2022, G2064 and G2065 were replaced by four new CPT® (Current Procedural Terminology®) codes, 99424, 99425, 99426 and 99427. The first of these new CPT codes provide formal reimbursement guidelines for services provided by physicians and qualified health care professionals (QHPs). The other two cover clinical staff time (nurses, for example) as directed by the physician or QHP.

Understanding that PCM is a timely and important model of care, let’s take a closer look at just what is principal care management, and how it can be used by clinical providers and other billing practitioners to supplement their efforts at managing patient care.

What is principal care management?

Fundamentally, principal care management is a model for the care of patients with a chronic illness for a period lasting three or more months. According to the CMS definition (via the AACP), the patient must also have had either a recent hospitalization or an acute risk of death, exacerbation or functional decline, or require management that’s “unusually complex due to comorbidities.”

In functional terms, PCM services involve care that stabilizes the patient’s condition as soon as possible, and then transferring the patient back to their primary care provider.

First, a physician or qualified health care provider (usually a nurse practitioner or physician assistant) works to create a disease-specific care plan, and then to make any necessary adjustments. Those ongoing changes are expected and built into the reimbursement guidelines — e.g., qualifying conditions are defined as requiring “frequent adjustments in the medication regimen.”

Next, clinical staff such as nursing professionals works under the direction of a physician or qualified health care provider to carry out that care plan. This specifically includes monitoring and managing the patient’s condition and medication, regular communication and coordination with the patient, and other day-to-day delivery functions.

Principal care management in context: PCM, TCM, CCM and RPM

PCM is frequently billed as part of a continuum with transitional care management (TCM). Along with TCM, principal care management is the basis of reimbursement for the post-discharge monitoring model of virtual care. The two are often used together when constructing care plans for patients with a single chronic condition that’s designated as complex or high risk.

Transitional care management covers the first part of treatment, beginning on the day when a patient is discharged and lasting for a total of 30 days of initial care. PCM is then used to cover the subsequent period of time, up to a year, while the physician, QHP and care team to work to stabilize the patient’s condition and try to prevent any further escalations or complications.

How is principal care management different from chronic care management (CCM)? Under CCM guidelines, patients much have two chronic conditions. Principal care management, however, is designed for the treatment of patients with just one, single high-risk disease.

And, like remote patient monitoring (RPM), principal care management can also be used to provide telehealth services (also known as remote or virtual care). That care is designed to be provided by a specialist, as applicable for the specific complex condition being treated. And because it exists separately from RPM and CCM, it can be billed during the same month as these services.

Preparing your practice for principal care management

Like RPM and CCM, primary care management is poised to become a key part of care delivery going forward. While reimbursement for PCM services can give providers a new revenue stream for the billing practitioner, it also helps to engage patients more in their care plan — thought to be an essential ingredient for success in patient care (and value-based care).

We’ll have a more detailed guide to the new PCM codes in our next installment. Until then, we invite you to download our handy Reimbursement Tree for an easy, at-a-glance summary of CPT Codes for PCM, RPM, CCM and more.

And if if your organization is looking for help putting together a principal care management plan, we may be able to help. Contact us now to connect to a CareSimple specialist.