Principal Care Management: Elements and Benefits

Beginning in 2020, the Centers for Medicare and Medicaid Services (CMS) created a new program called Principal Care Management (PCM).

The service is intended to provide additional care to patients with a single chronic condition or allowing a provider to treat a patient with multiple chronic conditions by focusing care solely on one of those chronic conditions.

Previously, CMS only allowed practices to be reimbursed for treating patients with two or more chronic conditions under their Chronic Care Management (CCM) program.

PCM was created to fill in the gaps, as many practices do see patients with only one chronic condition, but could stand to benefit greatly from focused care.

This new program stands to benefit millions of Americans, as the CDC reports that 6 in 10 people across America have one chronic disease.

Similar to CCM’s impact on healthcare, PCM is positioned to become an integral part of primary care, resulting in better health outcomes for patients while reducing overall healthcare costs.

ThoroughCare has added PCM into our care management software, enabling practices to leverage the rewarding reimbursement opportunities CMS has afforded them.

Because PCM is a very new program, not many providers have begun taking advantage of these opportunities.

We intend to help you navigate the rules of this new program, understand its value, and set you on a path to implementation just like we have with hundreds of clients with CMS’s other programs.

In this article, we’ll simplify everything you need to know to move forward with PCM at your practice.

What Is PCM?

As we stated above, PCM is intended to serve people with one chronic condition.

The requirements for PCM are very similar to the requirements for CCM.

To qualify for PCM, the patient must have a diagnosis expected to last between three months and a year, or until the death of the patient, may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Also similar to CCM, verbal, or written consent from the patient is required and must be documented by the practice.

One small 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.

Benefits of PCM

Just like CCM, there are benefits of PCM for both patient and provider.

Stabilization of Patient’s Chronic Condition

One of the primary goals of PCM is to address a patient’s chronic condition as quickly as possible, stabilizing it so their overall care can be returned to the patient’s primary care physician.

This would greatly reduce the health care costs the patient would bear, which is no small benefit.

The CDC reports that 90% of the nation’s $3.5 trillion in annual health care expenditures are attributed to people with chronic and mental health conditions.

Both patients and providers would benefit from the reduction in health care costs.

Prevention of New Diagnosis Arising

The benefit of addressing one chronic condition when it arises is it greatly reduces the chances of a new, second chronic condition arising.

Through all of CMS’s programs, one underlying benefit patients receive is the attention and focus given to them by their health care provider. This makes patients feel valued and safe, opening them up to trusting their provider and ultimately becoming more engaged in their own health.

When patients are more engaged in their health, they see better health outcomes.

Reimbursement Opportunities For Providers

CMS allows providers to be reimbursed for PCM, offering an additional revenue stream for your practice.

CMS has approved two new CPT codes to support PCM.

CPT Code: G2064

Practices may bill G2064 for 30 minutes of physician time per month at $78.68 per patient.

To meet CMS requirements, the practice must provide 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 with the following elements:

• One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
• The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
• The condition requires development or revision of a disease-specific care plan,
• The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

CPT Code: G2065

Practices may bill G2065 for 30 minutes of clinical/provider staff time per month at $39.70 per patient.

To meet CMS requirements, the practice must provide comprehensive care management for a single high-risk disease, at least 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month with the following elements:

• One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
• The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
• The condition requires development or revision of a disease-specific care plan,
• The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

Much like with CCM, practices can maximize reimbursement opportunities by also enrolling patients in a Remote Patient Monitoring (RPM) program.

By combining PCM and RPM together, not only will you be able to better improve the health outcomes for your patients, but maximize the revenue streams available to your practice.

Important CMS Reporting Rules

There are a few important rules providers must keep in mind when managing a PCM program.

• For the calendar year 2020, PCM services G2064 and G2065 are only reportable to Medicare and may not be accepted by private payers.
• PCM services G2064 and G2065 should not be billed together in the same month.
• PCM services cannot be billed for at the same time as CCM services or interprofessional consultations.
• Patients may receive PCM services from more than one clinician as long as the care provided is for different conditions per clinician.

How ThoroughCare Helps You Maximize Reimbursement with PCM

Our PCM solution offers mostly the same features and tools as our CCM solution, allowing you to better manage your patients.

Patient Consent and Enrollment Forms

With our software, you can start enrolling your patients today. We provide the consent forms and patient agreement templates that you can use and support verbal consent with date/time stamps.

Patient-Centered Care Plan Assessments

ThoroughCare's guided-interview automates the Patient-Centered Care Plan, taking the guesswork out of it. This tool can greatly improve the effectiveness and efficiency of your program.

Monthly PCM Time Logging

Logging the 30 minutes of care and conducting monthly updates is simple in ThoroughCare. Plus, all PCM summaries can easily be shared with your EHR.

The best part about our software is that it was built for clinicians, by clinicians. Additional functionality and features include:

Practices everywhere are choosing ThoroughCare to simplify their PCM program:

• Your own secure, HIPAA-compliant software portal
• Unlimited users and patients
• Live Dashboard showing current PCM minutes
• Guided-interviews for PCM Care Plans
• Task tracker (with timer) and Time Logging
• Monthly Update interface for clinical staff and providers
• Create Care Plan reports for the patient and other providers
• Easily download summaries and upload to your EHR
• Integrates with Annual Wellness Visit Software
• Easy Billing interface to easily submit Medicare reimbursement claims
• Tech Support via email and phone

Maximize Your Revenue and Improve Patient Health Outcomes with PCM

At the end of the day, your goal as a health care provider is to help your patients. Of course, you want to be properly compensated for the services you provide.

Through PCM, CMS allows providers to gain additional revenue streams and improve patient health outcomes.

While care management software isn’t necessary to run these programs, the benefits are numerous. That is why over 400 hundred providers across the country have chosen ThoroughCare as their care management software solution.

We stay focused on helping you, and ultimately, your patients.

Feel free to explore our learning center, as we have a wealth of information and resources on important care management topics.

If you’re interested in learning more about ThoroughCare, request a software demo to see our software in action.