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The Centers for Medicare and Medicaid Services (CMS) has recently introduced two reimbursement processes under Principal Care Management (PCM) this 2020. These processes may appear similar to the current Chronic Care Management (CCM) program offered by Medicare, but it has a few key differences. If you want to understand them better, this article will introduce you to what PCM is and how it differs from CCM.

What Principal Care Management Is All About

The new PCM codes will enable specialists to claim reimbursement for providing their patients with targeted care management services within their particular specialty area. As mentioned earlier, it has two billing codes:

  • HCPCS G2064 – $94 – This is the CCM program for single high-risk diseases. It will require at least 30 minutes of the physician’s or other qualified healthcare professional’s time every calendar month. The service should have the following elements:
    • One complex chronic condition lasting a minimum of three months, which serves as the focus of the care plan
    • The condition is of sufficient severity that it has been the cause of the patient’s recent hospitalization or places the patient at risk of hospitalization 
    • Their condition required the development or revision of a disease-specific care plan
    • The management of the condition is unusually complicated due to comorbidities
  • HCPCS G2065 – $40 – This is the CCM program for single high-risk diseases. It will require at least 30 minutes of clinical staff time directed by a physician per calendar month. The service should also have the elements mentioned in G2064.

Who Can Bill for Principal Care Management

Any physician or qualified health care practitioner can bill for PCM. 

Who Are the Qualified Patients of This New Code

Any patient with a condition that requires disease-specific care is recommended to take the PCM. They only need one condition to qualify for principal care management, but it is not limited to patients with only one chronic condition. The PCM is also for people who meet the following criteria.

  • A condition that is expected to last between three months to a year or until the patient’s death.
  • The patient was recently hospitalized or was placed at significant risk of death
  • The condition is too complex that primary care is not enough to manage it effectively
  • The condition requires the expertise of other, more specialized practitioners

What to Expect: Initiating Visit and Consent

Here is what will happen if you pursue the new care management program:

  • The billing practitioner will schedule an initial visit with new patients or patients they have not seen in a year.
  • During the meeting, the practitioner will educate their patient about principal care management. The topics to discuss should include:
    • The program and its nature
    • That only one practitioner per month can bill for a particular chronic condition
    • The patient has the freedom to stop the service whenever they want
    • Any other cost-sharing information
  • They should also obtain the patient’s informed consent. It can be verbal or in writing, and it must be documented in the patient’s health record. Certified EHR use is a requirement.

The Billing Notes Alongside Other Services: CCM and RPM

  • Chronic Care Management (CCM) cannot be billed simultaneously with PCM by the same billing practitioner.
  • Remote Patient Monitoring (RPM) can be billed simultaneously with PCM as long as the time is not counted twice. 

Conclusion

The new codes in Principal Care Management are an excellent opportunity for specialists to manage their patients’ disease-specific conditions. It will also remove the burden of managing other chronic conditions their patients have that are not related or relevant to their specialty. 

If you need help with chronic care management, look no further than Medistics Health. Whether you are a patient or a healthcare provider, we can simplify the healthcare experience for you. Contact us today to learn how we can assist you.

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