PCM

Principal Care Management

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.

What is Principal Care Management?

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.

PCM Eligibility Requirements

To qualify for PCM services, patients must meet all of the following criteria:

One complex chronic condition: A single condition expected to last at least 3 months that places the patient at significant risk of hospitalization, exacerbation, or functional decline
Condition-focused care plan: A documented care plan specific to the qualifying chronic condition, distinct from general care planning
Medicare beneficiary: Patient must be enrolled in Medicare Part B
Patient consent: Written or verbal consent must be obtained and documented before services begin
Monthly time tracking: Unlike APCM, PCM requires documentation of time spent each month, with a minimum of 30 minutes per billing period

Common Qualifying Conditions

Cancer
Heart Failure
COPD
CKD
Diabetes with Complications
Rheumatoid Arthritis
Lupus
Multiple Sclerosis
Parkinson's Disease

PCM Billing Codes

PCM is billed monthly using time-based CPT codes. Documentation of time spent is required each billing period:

CPT CodeDescription
CPT 99426First 30 minutes of physician/QHP time per calendar month - condition-specific care management
CPT 99427Each 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.

How CareStream Delivers PCM

CareStream manages PCM end-to-end, handling the condition-specific complexity while your practice retains clinical authority:

01

Patient Identification

Automated analysis of your EHR to identify patients with qualifying single complex conditions not already enrolled in CCM.

02

Condition-Specific Care Plans

Development of focused care plans tied to the qualifying diagnosis, meeting CMS documentation requirements.

03

Consent Collection

Compliant verbal or written consent workflows conducted by our care team.

04

Monthly Engagement

Regular non-face-to-face contact focused on the principal condition: medication adherence, symptom monitoring, care coordination.

05

Time Documentation

Automated tracking of all monthly billable time with audit-ready logs for every patient.

06

Escalation Protocols

Condition-specific escalation pathways that route clinical concerns to your team immediately.

07

Billing Support

Compliant claim generation for 99426 and 99427 with supporting documentation included.

PCM vs. CCM: Understanding the Difference

PCM and CCM are complementary programs, not competing ones. The right choice depends on your patient's condition profile:

  • Use PCM for patients with one complex chronic condition requiring focused, condition-specific management
  • Use CCM for patients with two or more chronic conditions requiring comprehensive multi-condition coordination
  • Both programs require monthly time documentation; PCM does not reduce that requirement
  • PCM is often used by specialists who manage a single condition domain for Medicare patients

Many practices run PCM and CCM simultaneously to maximize coverage across their entire Medicare population. Learn more about CCM →

Related Programs

Start Capturing PCM Revenue Today

We identify your eligible patients, manage the program, and handle billing so you can focus on care.

Get Started