Principal Care Management: Care Coordination for Specialty Practices

When the Centers for Medicare and Medicaid Services launched the Chronic Care Management (CCM) program in 2015, it was targeted to primary care practices, but the final rule didn’t exclude specialty practices from participating. But, helping patients manage multiple chronic conditions when their expertise was in just one of those conditions proved to be challenging for the specialty practices that did try their hand at CCM, says Kevin Franke, BSN, principal consultant for Casper, Wyoming-based Care Partner LLC. Now, specialty practices have another option. New in 2020, the Principal Care Management (PCM) program allows practices to obtain reimbursement for the care coordination they provide for a single, complex chronic condition.

While the vast majority of Medicare beneficiaries have multiple chronic conditions, CMS data show that a small percentage have just one. But, that’s not necessarily who PCM is for.

“With Medicare, it’s what they don’t say that’s important,” Franke says. “They always tell you what you can’t do, but oftentimes you have to interpret what you can do.”

For example, the rules around PCM state the same provider cannot bill for CCM and PCM in the same month. A patient could receive both CCM and PCM in the same month, provided those services were billed by different providers. Additionally, patients can receive PCM services from more than one provider for different conditions (e.g. a cardiologist for heart disease and an endocrinologist for diabetes).

How PCM and CCM differ

The biggest difference between PCM and CCM is how many chronic conditions it covers. PCM covers one, while CCM covers two or more. CCM’s scope involves total patient care management, while PCM manages disease-specific care.

Another difference is how each of these care models can be triggered. CCM is triggered by a general need for care coordination and communication. For PCM, there should be an exacerbation of the condition or a recent hospitalization.

Unlike CCM, which has a non-complex and complex code, there’s just a single one for PCM—all covered conditions are considered complex.

Another difference is the time that can be reimbursed. For non-complex CCM, providers can bill 20 minutes a month for care coordinated by clinical staff or 30 minutes a month for care coordination provided by a physician or qualified practitioner. (For complex CCM, additional time is required.) For PCM, 30 minutes of care coordination can be provided by a physician or other qualified health care professional (HCPCS Code G2064) or by clinical staff (HCPCS Code G2065). Providers can bill for only one of these codes per month.

CMS declined to create an add-on reimbursement code for PCM time spent beyond 30 minutes per month. However, the agency has indicated it will monitor PCM utilization to see if future revisions need to be made.

“Don’t stop tracking after 30 minutes,” Franke says. “You always want to know how much time you’re actually spending, even if you can’t be reimbursed for all of it.”

Requirements for PCM

In order to bill for PCM, providers need to get consent from the patient. Franke says patients may decline PCM services, due to the fact that it’s covered by Medicare Part B. Patients who have supplemental coverage will likely not pay out of pocket for PCM, but anyone without additional coverage might.

There are also strict documentation guidelines that providers need to follow. Not only do practices need to carefully document that patients meet the criteria for PCM, the various components of PCM need to be documented in the patient’s health record, including patient communications, communications with the patient’s PCP, medication adjustments, etc.

“With a program like this, it’s really important to have a very clear-cut, auditable trail that all of these requirements are being met every month,” Franke says. “There are different platforms available to assist meeting these requirements. I often work with one called CrossTX.”

The 30 minutes of time does not have to be spent face to face with the patient. It also can be used to create or revise care plans, follow up with patients via phone and refill prescriptions.

Billing for PCM takes the place of interprofessional consultations—providers cannot bill for both in the same month.

Overall, Franke, who has helped practices implement CCM programs, is optimistic that specialty practices will adopt PCM. “Whenever we hear ‘CMS,’ the natural response tends to be a groan,” he says. “But I believe CMS got this one right. This is about better patient care and providing practices a very deliberate way of taking care of their patients with additional revenue.”

Learn more about PCM and how it can complement CCM at the upcoming HealthTechS3 webinar, Bringing Care Coordination to Specialty Practices: Principal Care Management, on Thursday, Aug. 27. Join Franke and Faith Jones, MSN, RN, NEA-BC, director of care coordination and lean consulting for HealthTechS3, as they dive deeper into the CCM and PCM and how the two care coordination models intersect. Reserve your spot today.