Principal Care Management (PCM) Explained: A New Opportunity for Chronic Care
Mrs. Carter’s heart failure is stable... until it isn’t. One salty meal, one missed diuretic refill, one weekend of creeping edema, and a preventable ED visit is suddenly on the calendar. Her cardiology team already does the work between visits: medication titration calls, lab checks, coordination with primary care. Principal Care Management (PCM) is the structure and reimbursement pathway that turns that high-value, between-visit work into a consistent, trackable service for a single, high-risk condition when patients need more focused management.
What is PCM (and who it’s for)
Principal Care Management is a set of time-based care-management services for patients who have one serious chronic condition that is expected to last at least 3 months and that places them at significant risk of hospitalization, acute decompensation, functional decline, or death. PCM is furnished monthly and is reportable only when ≥30 minutes of qualifying work is completed in a calendar month; after 12 months, CMS requires another initiating visit to continue PCM services.
In practice, PCM formalizes what many specialists and primary-care teams already do: focused medication management, serial lab/imaging follow-up, disease-specific education, and coordination with other clinicians for a single, complex condition (for example, heart failure with recent decompensation, severe COPD, advanced CKD, decompensated cirrhosis, or complex cancer therapy). The goal is not to replace in-person visits, but to operationalize the crucial weeks between them.
how PCM differs from CCM
Chronic Care Management (CCM) supports patients with two or more chronic conditions expected to last 12 months or until death and that place the patient at significant risk; PCM supports patients with one complex, high-risk condition expected to last ≥3 months. Both are calendar-month, time-based services with patient consent and a shareable, patient-centered care plan, but PCM narrows the focus to a single condition where intensified management is needed. [1] Together, CCM and PCM let practices match the service to the clinical reality—whole-patient versus single-condition management.
APCM vs. PCM: complementary, not redundant
Advanced Primary Care Management (APCM) is a distinct CMS service (HCPCS G0556–G0558) intended to bundle and operationalize primary-care-led management across domains. APCM is ideal when the entire primary-care relationship—not just one disease—requires structured, continuous management. PCM, by contrast, is a focused, single-condition monthly service billed with CPT 99424–99427. Practices can use PCM inside a broader APCM strategy: PCM for the dominant condition today, APCM (or CCM) when the needs broaden tomorrow.
Eligibility and required elements (a simple checklist)
Before enrolling a patient in PCM, confirm the following:
- The patient has one serious chronic condition expected to last ≥3 months and carrying significant risk (for example, hospitalization or functional decline).
- An initiating visit establishes the clinical need and shared plan; after 12 months, another initiating visit is required to continue PCM.
- A patient-centered, shareable care plan focused on the single condition is established, implemented, revised, or monitored.
- Work is non–face-to-face and time-based across the calendar month; do not bill if total time is <30 minutes that month.
- Only one practitioner/facility furnishes and is paid for a given care-management service for a patient in a calendar month; the consent conversation must reflect this and the patient’s right to stop services.
Taken together, these requirements ensure PCM is clinically justified, patient-centered, and auditable: exactly what payers and patients expect from modern longitudinal care.
Billing basics and code set
CPT descriptors specify which codes are for practitioner-personal time versus clinical-staff time; use add-on codes only when the base-code time is met in the same month. Confirm current payment using the Medicare Physician Fee Schedule (PFS) for your locality and date of service.
Five ways PCM creates value
Here are five ways PCM creates value:
- Faster medication optimization. A heart failure patient starts guideline-directed therapy; weekly titration and lab checks happen via the PCM workflow, catching rising potassium early and achieving target dosing sooner. This is precisely the single-condition management PCM was designed to support.
- Prevention of exacerbations. A COPD patient with frequent bursts receives a monthly check-in that reviews inhaler technique, fills, and symptoms; red flags trigger a same-week visit. The structure reduces avoidable acute care in many populations when executed consistently.
- Tighter specialty–primary care coordination. Oncology uses PCM to surveil chemotherapy-related toxicities; standardized symptom scripts and fast-track escalation keep patients safer between infusions.
- Patient engagement between visits. A CKD patient receives reinforcement on diet, home BP checks, and sick-day medication holds. The focused, monthly cadence builds confidence and adherence where it matters.
- Operational reliability. Time-stamped logs, shared care plans, and the “one practitioner per month” rule reduce duplicate work and billing friction while making the between-visit work auditable.
Across these scenarios, PCM turns good intentions into reliable, measurable processes—improving experience for patients and predictability for teams.
Practical applications across specialties
PCM offers several practical applications across specialities:
- Cardiology: Decompensated heart failure, post-MI medication up-titration, refractory angina—when one condition drives risk and workload.
- Pulmonology: Frequent COPD exacerbations or severe asthma requiring step-up therapy and close follow-up.
- Nephrology: Rapidly progressive CKD or complex electrolyte management where small changes matter.
- Endocrinology: Labile type 1 diabetes on new technology, or complex endocrine therapies demanding close monitoring.
- Oncology: Symptom-toxicity management during a defined regimen with predictable surveillance needs.
Always confirm that one condition truly dominates the care need for PCM; use CCM or APCM when multiple conditions or comprehensive primary-care needs are the primary driver.
Implementation strategy
Implementing PCM can benefit from a "start small and then build on patient fidelity" approach, especially for practices that do not have prior experience in running this program:
- Identify candidates at discharge or after exacerbation. Use EHR flags for recent hospital/ED use, steroid tapers, or medication starts that imply higher-touch management for one condition.
- Stand up a disease-specific script and care-plan template. Begin with one condition (for example, heart failure). Include symptom triggers, lab cadence, and clear escalation criteria.
- Decide who furnishes the time. For complex judgment calls, favor practitioner time (99424/99425). For standardized surveillance, use clinical-staff time (99426/99427) under physician/QHP direction.
- Close the loop visibly. Push every escalation and outcome back into the care plan so all clinicians see the thread.
- Re-assess at 12 months. If needs broaden beyond one condition, consider transitioning to CCM or APCM, with a new initiating visit as required.
Starting narrow, measuring fidelity, and expanding deliberately is the fastest way to prove value without overwhelming staff.
Compliance and audit readiness
Building robust processes for compliance and audit readiness is fundamental. Some of the things to consider are:
- Consent content. Document patient consent covering service availability, cost-sharing, and that only one practitioner/facility may furnish and be paid for the service in a calendar month; include the patient’s right to stop services at month-end.
- Time accounting. Keep contemporaneous logs by calendar month that tie to the billed code combination.
- Care plan. Maintain an up-to-date, shareable, patient-centered plan focused on the single condition.
- Initiating-visit timing. Record the initiating visit date and, if continuing beyond 12 months, the subsequent initiating visit.
- Code integrity. Use add-on codes only when base-code thresholds are met in the same month; attribute practitioner vs. clinical-staff time correctly.
Thoughtful documentation isn’t red tape; it’s how you make excellent between-visit care legible to payers—and repeatable for your team.
Every preventable exacerbation you avoid is a better week at home for your patient—and less chaos for your team. Lara Health streamlines eligibility, scripts, care plans, time tracking, and documentation so single-condition management becomes routine rather than heroic. Book a demo with Lara Health and see how straightforward PCM can be when the right workflows are at your fingertips.
FAQs
Who can bill PCM?
Physicians and other qualified health care professionals can bill PCM; clinical staff may furnish services under their direction when using the appropriate clinical-staff codes.
Can multiple clinicians bill PCM for the same patient in the same month?
No. CMS policy requires that only one practitioner/facility is paid for a care-management service per patient per calendar month, and consent must reflect that.
Does PCM replace CCM or APCM?
No. PCM is for one high-risk condition. Use CCM when two or more conditions require longitudinal management, or APCM when primary-care-led, comprehensive management is appropriate.
Are commercial payers covering PCM?
Coverage varies by payer and contract. Many plans do reimburse CPT 99424–99427, but verify locally.
What about payment amounts?
Payment varies by year and locality. Use the current Medicare Physician Fee Schedule lookup for accurate, site-specific rates.
Sources
- Centers for Medicare & Medicaid Services (CMS). Chronic Care Management Services MLN Booklet (MLN909188). 2025.
- CMS. Advanced Primary Care Management (APCM) Services overview. 2025.
- CMS. Medicare Benefit Policy Manual (Pub. 100-02), care-management consent and “one practitioner per month” rules. 2024.
- American Medical Association (AMA). CPT® 2025 descriptors for PCM (99424–99427) and practitioner vs. clinical-staff time; MAC guidance corroborations. 2024–2025.
