Payment Reimbursement Tips: What You Need to Know about Principal Care Management (PCM)

Is your oncology practice ready for Principal Care Management (PCM)? And, did you know you can bill for care services you’re already providing? Let’s take a deep dive and better understand the importance of PCM and how you can better leverage this model of care as part of your patient-centered care strategies.

What is Principal Care Management?

Beginning in 2015, CMS has placed an emphasis on improving quality of care and outcomes by instituting care management programs. Principal Care Management (PCM), a sibling of Chronic Care Management (CCM), was introduced by CMS in 2020 as a tool for specialty providers, such as oncologists, to use to help patients and providers better manage care in between visits for those patients with a high-risk or chronic condition. Recognizing that care management requires provider and clinic staff time and resources, CMS adopted CPT codes to reimburse clinics for their efforts and time.

Like CCM, PCM focuses on managing patient care outside of physical appointments and routing services in between appointments. This includes patient follow-up in the form of medication management or even reviewing a patient’s after-visit summary with them so they can better understand their care plan. PCM activities involve a range of services commonly you currently provide today, which include, for example, follow-up after hospital visits, referral coordination, management of transitions of care, revising care plans, and assisting with the receipt of preventative services.

Why is this important? Many clinics, including in particular oncology clinics, are looking at ways to fill the gap in reimbursement payments when the Oncology Care Model (OCM) sunsets in June 2022. Luckily both PCM and CCM are two programs that continue to encourage the care management model adopted by OCM and recognize the need to compensate providers for these additional services.

What is it?

PCM enables specialists, e.g. oncologists, to deliver and bill for care management services that is disease-specific to their patients. PCM mirrors CCM in many ways, but focuses on a single high-risk or chronic condition.

What’s the Primary Benefit of PCM?

A primary benefit of the PCM codes is that CMS pays for the care management of Medicare patients with a single, high-risk chronic condition, such as cancer. Significantly, specialists managing just one condition, like cancer, can provide PCM services without having to identify a second comorbidity which is required for CCM services. This helps patients by allowing them to receive important care management services such as routine symptom monitoring, medication adherence check-ins, and coordinated care–all important factors to ensure continuity of care and longitudinal care. 

The transitioning of care from clinic-provided care to self-care in terms of medication management and follow-up visits can be challenging for patients, especially those with complex chronic conditions. With PCM, clinical staff can support this transition, enabling better-directed self-care, and the clinic can be compensated for this time. The PCM codes enable clinical staff to bill incident-to the billing provider under general supervision, which means that the clinical staff can be located at a centralized location and do not need to be in the same office location as the provider (though the provider must be available to answer questions).

New Codes in 2022 for PCM Services

The four CMS-established codes1 for PCM services are as follows:

CPT Code CPT Code Description 2022 Non-Facility Payment Amount
Physician or Qualified Professional
99424 Principal care management services for single complex chronic condition with significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, first 30 minutes provided personally by qualified health care professional, per calendar month $83.40
99425 Principal care management services for single complex chronic condition with significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, each additional 30 minutes provided personally by qualified health care professional, per calendar month $60.22
Clinical Staff under Supervision
99426 Principal care management services for single complex chronic condition with significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, first 30 minutes of clinical staff time directed by qualified health care professional, per calendar month $63.33
99427 Principal care management services for single complex chronic condition with significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored, each additional 30 minutes of clinical staff time directed by qualified health care professional, per calendar month $48.25

What Else Should I Know About PCM Reimbursement?

One important factor to note is that PCM compensates providers for activities performed outside of routine in-person (face-to-face) visits with their patients. This includes time spent developing care plans, patient follow-up related to medication management, and discussion of after visit summaries via the phone. PCM can be billed concurrently with other care management programs, provided that the patient has consented to each of these services. Clinicians can provide PCM services simultaneously with other valuable care management programs such as Transitional Care Management, Remote Physiological Monitoring, and the new Remote Therapeutic Monitoring codes. Fortunately, this care coordination process is familiar to many clinics that have leveraged remote patient monitoring platforms, such as Health Tracker during the pandemic. 

To be eligible for PCM services, patients must meet the following CMS criteria:

  • The patient must have one complex chronic condition lasting at least 3 months, which is the focus of the care plan;
  • The patient’s condition must be severe enough that the patient was recently hospitalized due to their condition or is at risk for hospitalization. The patient’s condition requires the creation or revision of a disease-specific care plan; and
  • The patient’s condition is the type which requires frequent adjustments to the patient’s medication regimen; and/or managing the condition is unusually complex due to associated comorbidities.

Navigating PCM Implementation & Future Considerations

A core tenant of Navigating Cancer is to dramatically improve the lives of cancer patients.  We believe PCM is a fundamental tool in achieving this goal. Navigating Cancer is continuously innovating to enable triage and care management functionality in our full suite of integrated, digital oncology solutions. Using Navigating Cancer’s platform, oncology clinics can leverage our PCM-based workflows, which is integrated with our triage system, enabling clinical staff and clinicians to provide meaningful care management services.  

Navigating Cancer continues to engage in advocacy with CMS and industry groups to inform future, value-based care models as the payment care model landscape continues to evolve.  Navigating Cancer focuses on providing clinics with insight into optimizing value-based care savings, strategies around efficient and quality care management, and other targeted measures to drive quality care and reimbursement for the practices. This is one of many reasons why Navigating Cancer’s solutions continue to be widely adopted as the industry standard in oncology. 

Want to learn more? Let’s Chat.

1 CPT 2022 Professional Edition. American Medical Association, 2021.

2 https://www.cms.gov/medicare/physician-fee-schedule/search

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