What is Principal Care Management?

CMS introduced two new reimbursements for care management for the calendar year 2020 named: Principal Care Management.

Principal Care Management is also known as PCM  and its very similar to Medicare’s Chronic Care Management program(CCM) with a few key differences. Under the new PCM codes, specialists may now be reimbursed for providing their patients with care management services that are more targeted within their own particular area of specialty.

Principal Care Management Billing Codes:

1. HCPCS G2064 ($94)
   1. Comprehensive care management services for a single high-risk disease, at least 30 minutes of physician or other
      qualified health care professional time per calendar month.
   2. A disease-specific care plan is required.
2. HCPCS G2065 ($40)
   1. Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30
      minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
   2. A disease-specific care plan is required.

Who Can Bill for PCM:

1. The billing practitioner must be a physician or a qualified health care practitioner (QHCP).

Eligible Patients / Qualified Patients: PCM services will typically be triggered by exacerbation of a qualifying condition such that disease-specific care is warranted.

1. The condition will typically be expected to last between 3 months and 1 year, or until the death of the patient.
2. May have led to a recent hospitalization and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and
3. It is of such complexity that it cannot be managed effectively by primary care and requires management by another, more specialized practitioner.

The patient only needs one chronic condition to qualify for principal care management, as long as the above-mentioned requirements are met.  PCM is not limited to patients with only one chronic condition.

Initiating Visit and Consent:

1. The billing practitioner must schedule an initiating visit for new patients and patients that have not been seen in a year. They must educate the patient on principal care management, and obtain the patient’s informed consent.
2.  The patient’s informed consent can be obtained verbally or in writing and it must be documented in the patients health record. (Certified EHR use is a requirement)
3. Important topics to discuss with patients while obtaining consent are:
   1. The nature of the program and what it is.
   2. Only one practitioner can bill in a month for the specific chronic condition.
   3. The patient can stop services when they want.
   4. Any cost-sharing information.

Concurrent Billing with Other Services (CCM) and (RPM)

1. Remote Patient Monitoring (RPM) can be billed concurrently with principal care management as long as the time is not counted twice.
2. Chronic Care Management cannot be billed concurrently with principal care management by the same billing practitioner.

In short, this new code is a great opportunity for specialists to manage their patient’s disease-specific condition(s) while removing the burden of managing additional chronic conditions the patients have that are not relevant to the physician’s specialty.

If you’d like to learn more about Principal Care Management or any of the connected care billing codes. Send us an email: [email protected] or schedule a time to speak with us today.

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