Medical reimbursements are tied to Current Procedural Terminology (CPT) codes. They categorize and specify billing rates and rules for procedures, treatments, and care services.
If you’re a medical care provider, you likely know this. But do you know the rates and workflows for Medicare’s wellness programs? Like, Principal Care Management (PCM)?
Knowing the billing codes for PCM will give you a better idea of what’s expected, both by the patient and Medicare.
Understanding billing codes will also help you project revenues and optimize your staff’s capacity. Without this information, you risk disorganization and a clouded outlook.
At ThoroughCare, we’ve worked with more than 600 clinics and physician practices to help them streamline and capture Medicare reimbursements.
Our software assists with PCM’s rules and regulations, and it tracks all activities related to providing the program, such as care plan creation, making it easier to bill for.
In this article, we’ll briefly review the requirements of PCM, as well as the program’s CPT codes. We’ll also provide an example return-on-investment (ROI) of an effective program.
With this information, you’ll better understand principal care billing expectations and standards. You’ll also see how care coordination software can simplify the program.
How Does Principal Care Management Work?
Principal Care Management (PCM) works much like Chronic Care Management (CCM). Both programs help address chronic illness, but PCM is focused on treating only one, sole issue.
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.
For your patient to participate in PCM, they must provide written or verbal consent, which in turn must be documented by your practice. Care management software can help record this in case of an audit by Medicare.
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
- Telephone calls
- Physician reviews
- Referrals
- Prescription refills
- Chart reviews
- Scheduling appointments/services
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.
How to Bill for Principal Care Management
There are five items required when submitting a claim through CMS:
- 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
- Provider name
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.
The Centers for Disease Control and Prevention (CDC) estimates that six in 10 U.S. adults live with one chronic condition. And according to this same agency, these conditions are the leading driver behind the U.S.'s high healthcare costs.
As the provider, principal care for chronic conditions can help your practice address a national problem through a value-based care lens.
Reduced hospital visits and improved preventive care can help satisfy certain performance indicators measured by Medicare. This can help providers sustain or improve their Merit-based Incentive Payment System (MIPS) score, which can raise reimbursement rates.
PCM can also strengthen the relationship between your patients and your practice. The structure of the program, with its monthly touchpoints and care team access, can improve patient engagement.
How Can Principal Care Management Produce Revenue?
As for PCM reimbursement rates, what is the revenue opportunity of the program?
What if you also enrolled 100 of these same patients in RPM?
Offering a PCM program can generate revenue, as well as broaden care access for your patient. The combination is inherently valuable.
Streamline Principal Care Management With Software
To deliver and document principal care services, you’ll want a system in place to manage your program.
A practical resource, such as care coordination software, will keep key details from being lost or overlooked. This will promote efficiency for you and your staff and help patients succeed.
Care coordination software can streamline the creation of patient care plans, support staff workflows, and simplify billing. ThoroughCare’s software solution offers these exact features.
With a clinician’s eye, we’ve designed an intuitive platform that untangles the entire PCM process, so you and your patients can capitalize on it.
Our care coordination software enables you to offer a whole suite of wellness services that pair well with PCM, such as RPM or Transitional Care Management (TCM).
