Focused monthly care coordination for Medicare patients with one complex chronic condition. PCM fills the gap for patients who don't qualify for CCM's two-condition minimum but still carry significant care burden.
Principal Care Management (PCM) is a CMS program that reimburses providers for condition-specific care coordination for Medicare patients managing a single high-complexity chronic condition. Introduced in 2020, PCM addresses a critical gap left by CCM: patients with one serious diagnosis who require just as much focused management as those with multiple conditions.
Unlike CCM, PCM is condition-specific rather than comprehensive. The care plan and monthly activities are centered on a single complex diagnosis, making it ideal for specialists and primary care providers who own management of a particular condition for their patients.
Revenue opportunity: PCM captures reimbursement from a previously unbillable patient segment: those with one serious chronic condition. Many practices find 20-30% of their Medicare panel qualifies exclusively for PCM, not CCM.
To qualify for PCM services, patients must meet all of the following criteria:
PCM is billed monthly using time-based CPT codes. Documentation of time spent is required each billing period:
| CPT Code | Description |
|---|---|
| CPT 99426 | First 30 minutes of physician/QHP time per calendar month - condition-specific care management |
| CPT 99427 | Each additional 30 minutes of physician/QHP time per calendar month |
Note: PCM requires monthly time documentation, unlike APCM which uses a complexity-based tier system. CareStream tracks and documents all time automatically.
CareStream manages PCM end-to-end, handling the condition-specific complexity while your practice retains clinical authority:
Automated analysis of your EHR to identify patients with qualifying single complex conditions not already enrolled in CCM.
Development of focused care plans tied to the qualifying diagnosis, meeting CMS documentation requirements.
Compliant verbal or written consent workflows conducted by our care team.
Regular non-face-to-face contact focused on the principal condition: medication adherence, symptom monitoring, care coordination.
Automated tracking of all monthly billable time with audit-ready logs for every patient.
Condition-specific escalation pathways that route clinical concerns to your team immediately.
Compliant claim generation for 99426 and 99427 with supporting documentation included.
PCM and CCM are complementary programs, not competing ones. The right choice depends on your patient's condition profile:
Many practices run PCM and CCM simultaneously to maximize coverage across their entire Medicare population. Learn more about CCM →
We identify your eligible patients, manage the program, and handle billing so you can focus on care.
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