Principal Care Management Services (PCM)

CMS has introduced several non-face to face and in person care management services over the last few years. To date, around 3 million unique beneficiaries (9% of the Medicare fee-for-service population) receive these services annually, with higher use of chronic care management (CCM), transitional care management (TCM), and advance care planning (ACP) services.

Physician Fee Schedule Final rule 2020 which is posted here introduces a new non-face to face service for care management for the patients with only one chronic condition: Principal Care Management (PCM) services, which describes care management services for one serious chronic condition. Here a qualifying condition will typically be expected to last between 3 months and 1 year or until patient’s death and puts the patient at a significant risk for decline as well as death.

PCM is set apart from the CCM codes that require patients to have two or more chronic conditions. Although CMS has not proposed any restrictions on the specialties that could bill for PCM, most of these services will be billed by specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management. The treating clinician may need to provide a disease-specific care plan or may need to make frequent adjustments to the patient’s medication regimen.

In addition to the coding changes proposed to the existing CCM codes, CMS proposes a new Principal Care Management payment and coding structure. This new service is in recognition of the considerable time needed to manage one complex chronic condition.

  • HCPCS code G2064 – Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, 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 patient at risk of hospitalization or have been the cause of a recent hospitalization,
    • Specific condition requires development or revision of 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 CMS proposes a work RVU of 1.28.
  • HCPCS code G2065 – 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 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 patient at risk of hospitalization or have been cause of a recent hospitalization,
    • The condition requires development or revision of 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. CMS proposes a work RVU of 0.61.

An expected outcome of PCM is for the patient’s condition to be stabilized by the treating clinician so that overall care management for the patient’s condition can be returned to the patient’s primary care practitioner. If the beneficiary only has one complex chronic condition that is overseen by the primary care practitioner, the primary care practitioner will also be able to bill for PCM services.

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