To qualify for PCM, your patient must have a diagnosis that is expected to last between three months to a year or is life-long. The condition must be associated with recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation or decompensation, or in a state of functional decline.
Another key difference between PCM and CCM is the time required for billing. While CCM has a 20-minute requirement, PCM has a 30-minute requirement before it can be billed.
Services are delivered through remote interactions, allowing your patient to stay at home. These services can include:
A monthly clinical review
Services are based on a patient’s individual care plan. This document is a comprehensive guide to a patient’s goals, health history, and behavior. It is created in collaboration with the patient when their PCM enrollment begins.
Medicare Part B covers 80% of this benefit for patients. Practices, on average, can receive $61 for 30 minutes of service per month. Additional opportunities to meet higher billing thresholds are available, as we will detail below.
CPT Codes for each program you’re managing for the patient
ICD-10 codes tied to each of the conditions you’re managing within that program
Date of service
Place of service
While it’s not needed, it is helpful to know the care manager assigned to a patient in case you’re ever audited: When billing, you’ll calculate the time spent with each of your patients monthly.
These are the four steps you’ll take when billing:
Verify CMS requirements were met for each patient each month
Submit claims to CMS monthly
Send an invoice to patients receiving CCM services monthly
Make sure there are no conflicting codes that have been billed
CPT Codes for Principal Care Management
Below, we break down the four types of billing codes for PCM.
One set of codes, as clarified in the above graphic, accounts for services when delivered by clinical staff. The other set covers services when rendered by the provider.
These CPT codes do not necessarily represent any differences between actual services offered. They only account for who provides them. This will be determined by either the complexity of your patient’s condition or your discretion.
That said, it is important to use the code that is most accurate, in case of an audit by Medicare.
Billing Principal Care Management with Remote Patient Monitoring
Medicare allows your patients to enroll in both its principal care and Remote Patient Monitoring (RPM) programs. Together, both offerings can be an effective preventive health solution, working in tandem.
As your patient works with your practice to address their chronic condition, RPM can provide a stream of data to inform better care decisions. Often, RPM is used to monitor chronic conditions by collecting patient vitals daily.
Your practice can use RPM to target your patient’s particular condition by learning about the specific factors that influence it, such as blood pressure or blood glucose.
If you do enroll a patient in both programs, be sure to receive clear consent from the patient for each enrollment. Medicare will require this information, especially if your practice is audited.
If you’re using care coordination software, patient consent will be automatically documented.
As well, it is important that when billing for both PCM and RPM, you record billable time for each program. So, for PCM you would record 30 minutes and then an additional 20 minutes for RPM.
What is the ROI of a Principal Care Management Program?
The phrase return on investment (ROI) holds a financial connotation, but a “return” isn’t entirely dependent on monetary value. General benefits are equally important, especially with regard to a person and their health.
Your patients will benefit from PCM because it places a preventive eye on their well-being. It also expands access to care without the burden of office visits. Minimizing office or hospital time is a crucial point of value.
By allowing patients to stay at home, there’s less pressure on you and your staff, and there are more opportunities for high-risk patients to be seen. This leads to an overall improvement in the quality of care you and your practice provide.
PCM can also help address the broad implications of chronic disease and the burden it places on our healthcare system. Chronic conditions can lead to additional illnesses and health complications.