Principal Care Management (PCM)
for Patients With High-Risk Conditions
Clinii’s Principal Care Management (PCM) platform supports providers treating patients with a single high-risk condition that requires focused clinical attention. From enrollment to task tracking and compliant billing, Clinii helps you deliver reimbursable care while reducing administrative burden. Our PCM tools are EMR-integrated, scalable, and designed to meet all CMS requirements.
What is Principal Care Management?
Principal Care Management (PCM) focuses on patients with a single high-risk chronic condition, providing tailored care coordination, specialist support, and comprehensive management to improve overall health outcomes.
1. A Targeted Approach to Chronic Conditions
Managing patients with a single high-risk chronic condition requires a level of precision and attention that standard care models often don't allow. PCM offers a way to concentrate efforts into one serious condition (such as diabetes or congestive heart failure) allowing for more targeted care. This focused approach enables providers to identify specific interventions, reduce the risk of complications, and engage more deeply with the patient.
2. Improve Continuity and Accountability
Maintaining continuity between visits can be a major challenge in chronic condition care. PCM supports providers in creating structured relationships with patients that extend beyond periodic in-person appointments. Regular touchpoints—whether through calls, secure messages, or virtual check-ins—ensure that providers can actively monitor patients' conditions. This continuity helps build patient trust and encourages better adherence to care plans.
3. Enhance Clinical Efficiency
PCM can help alleviate the time constraints that providers often face by shifting some of the monitoring and coordination tasks to a structured, reimbursable model that runs in parallel with regular care. By designating specific care team members to manage PCM tasks, physicians can ensure patients receive comprehensive attention without disrupting clinic flow, ultimately improving both quality and efficiency of care delivery.
4. Strengthen Patient Engagement
Patient engagement is a vital aspect of managing chronic conditions effectively. PCM enables providers to build closer relationships with their patients that prioritize the patient’s individual needs. By focusing on education, medication adherence, and self-management strategies, providers can empower patients to take a more active role in their health.
5. Meet Value-Based Goals
Healthcare providers working within Value-Based Care models are under growing pressure to demonstrate outcomes and reduce unnecessary costs. PCM programs help address these demands by reducing emergency visits and hospital readmissions. Providers can leverage PCM to align clinical efforts with reimbursement incentives tied to improved care quality and cost savings.
6. Leverage Software for Scalable, Compliant PCM
Implementing PCM effectively requires careful coordination, time tracking, and documentation—all of which can be challenging to manage manually. Clinii’s AI-powered platform streamlines these processes by automating routine tasks, flagging eligible patients, and ensuring all CMS-required elements are met for billing. Providers benefit from intuitive dashboards, secure communication tools, and integrated time logs that make compliance easy and billing seamless. With the right software, practices can scale PCM programs efficiently while maintaining high standards of care and accountability.
CPT Codes
Complex PCM: Staff
Complex PCM: Provider
Frequently Asked Questions About Principal Care Management
1. What is Principal Care Management?
PCM is a CMS-defined care program that supports patients with a single serious chronic condition. It includes structured care planning, coordination, and monthly non-face-to-face check-ins with clinical staff or providers.
2. Who Qualifies for PCM?
Patients must have a single, high-risk chronic condition that is expected to last at least three months and requires frequent medical management. Conditions may include cancer, chronic kidney disease, or congestive heart failure.
3. Which CPT Codes Are Used for PCM Billing?
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99424: 30+ minutes of clinical staff time under provider supervision
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99425: Each additional 30 minutes
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99426 / 99427: Time spent directly by the billing provider
4. What is the Difference Between PCM and Complex PCM?
PCM and Complex PCM differ in the intensity and complexity of care provided to patients with chronic conditions. PCM focuses on patients with a single high-risk or complex chronic condition, offering management and coordination tailored to that specific condition.
Complex PCM is designed for patients requiring a higher level of care due to the severity or complexity of their single chronic condition. This service involves more intensive care planning, increased monitoring, and more frequent adjustments in the care plan, often requiring more direct engagement by the provider, compared to the standard PCM approach.
5. Which Practitioners Are Eligible to Bill Medicare for PCM?
Physicians (regardless of specialty), advanced practice registered nurses, physician assistants, clinical nurse specialists, certified nurse-midwives, or the provider to which such individual has reassigned their billing rights
are eligible to bill Medicare for PCM. Other non-physician practitioners, limited-license practitioners (e.g., clinical psychologists or social workers), and providers not eligible for reimbursement under the Medicare Physician Fee
Schedule (e.g., pharmacists) cannot bill for PCM.
6. When Filing a Claim for PCM, What Should Be Listed as the Date of Service?
The billing practitioner may list the date of service as the day on which the 30-minute minimum requirement is satisfied, or any day thereafter through the end of the calendar month. If the beneficiary dies during the month, the claim for PCM will be paid only if the date of service is prior to the date of death.
7. Can PCM Be Billed Alongside CCM?
No. PCM and CCM cannot be billed concurrently for the same patient. However, a patient may transition from PCM to CCM if their condition profile changes. Clinii tracks and alerts you to these eligibility shifts automatically.