Principal Care Management (PCM): A Complete Guide for Providers

Principal Care Management (PCM) is a Medicare-supported program aimed at comprehensive care for patients with one high-risk chronic condition. Unlike Chronic Care Management (CCM), which deals with multiple chronic conditions, PCM zeroes in on one complex condition which increases the likelihood of hospitalization, acute exacerbation, functional decline, or even death. This is a program that the Center for Medicare & Medicaid Services (CMS) introduced in 2020, which allows providers to give focused care, while earning revenue through reimbursements. This guide looks at the components of PCM, its benefits ,software solutions, pricing, and its components to aid providers for adequate implementation. 

What is PCM and How Does It Work? 

PCM is aimed at patients suffering from a chronic condition lasting a minimum of three months. It requires specialized care due to the complexity or severity of the condition. Examples of such conditions are uncontrolled diabetes, severe asthma, or advanced hypertension. PCM services include a dedicated care plan, close monitoring, and coordination with other healthcare professionals, which in most instances is provided through telehealth.

Let’s say there’s a patient who has been diagnosed with severe asthma and visited the emergency room recently. A PCM enrollment is done by the pulmonologist who formulates a care plan to reshuffle the medications, and sets up monthly check-in calls to gauge symptom progression. The clinical team monitors the patient remotely, helping to take action if things worsen. This integrated technique controlling the patient’s difficult to manage condition improves their overall health with less reliance on the hospital.

Main Features of PCM

**PCM has identified a few central parts that make it work:**

Patient Eligibility: A patient is eligible if they have one chronic problem that is difficult to manage and survives for over three months.

Care Plan: With the patient’s engagement, one illness-specific care plan is created that details the objectives, interventions, and the timelines for follow-ups.

Consent: Whether verbal or written, consent details need to be captured in some form, ensuring the patient is briefed on the services and possible co-pay(s).

Time Requirements: Clinical Personnel have to meet a threshold of 30 minutes in a month for PCM tasks which include overseeing medication, care coordination, or direct patient contact.

Coding for Reimbursement: PCM has 4 dedicated CPT codes, 99424 and 99425 for Physicians or eligible professionals for 30 and additional 30 minute increments. 99426 and 99427 are for clinical staff. The codes are geared to reimbursement pcm services.

Benefits of PCM

Both the patients and the providers of PCM reap the benefits. Patients receive the care they need without the added complexity of hospitalization. With PCM, providers strengthen patient relationships and receive extra revenue through monthly touchpoints. The CDC reports that 90% of U.S. healthcare costs stem from chronic conditions. PCM’s proactive methodology enables the management and stabilization of chronic conditions, reducing overall spending.

A good example is a cardiologist attending to a patient with uncontrolled, advanced hypertension. The PCM model allows the cardiologist to adjust medications, collaborate with a dietitian, and monitor blood pressure through remote and connected devices. This diminishes the need for emergency visits helping the patient and the healthcare system saves money while the provider earns revenue.

PCM Software Solutions

To PCM to run smoothly, thorough care, HealthArc, and CareVitality offer chronic care management software that enable the features listed below.

Centralized Patient Records: Store patient history, care plans, medications, and retrieve with ease.

Automated Care Plans: Guided interviews offered by care plans ThoroughCare help streamline the creation of care plans.

Time Tracking: Their monthly care activity can be documented for the 30 minutes required to be billed for accurate payment.

EHR Integration: Share PCM summaries directly with electronic health records (EHRs).

Secure Data Storage: Maintain HIPAA compliance through encryption and multi-level authentication.

These technologies help lessen administrative duties, allowing healthcare providers to concentrate on looking after the patients. An example would be HealthArc’s integration with 55 EHRs, which allows sharing a patient’s respiratory data in real time, thus enhancing real time data sharing.

HealthArc Pricing Model

Pricing for PCM Software varies with practice size and features. Each Practice is a smaller organization and will be charged $500. HealthArc seems to charge around $10 to 15 dollars a month provided there are a preset number of enrolled patients. CareVitality only charges after a provider receives reimbursement from Medicare, charging a flat fee. HealthArc’s model seems to cater best to larger corporations and practice zealous providers and receive almost $500 to $1000. For best pricing, providers should speak directly to vendors specializing in integrations and modifications.

Getting the most from PCM

Engage staff for proper documentation, train them on CPT coding, and tackle eligible patients during Annual wellness checkups. The combination of PCM and RPM is a win-win for both, though submission of claims should be based on time separately to optimize revenues and outcomes. Practices will be provided with software which will assist expensive outcomes and as a result reduce costs and enhance practice.

Visit CMS for more details on PCM reimbursement. For software pricing, reach out to companies like ThoroughCare or HealthArc.