2020 CMS Code Updates: Principle Care Management (PCM)

December 11, 2019

CMS is offering a new code called Principle Care Management (PCM) and is built for a patient with a single chronic condition diagnosis expected to last between three months and a year, or until the death of the patient.

Orb Health

With the New Year, Centers for Medicare and Medicaid Services (CMS) has gifted us with a new program – Principal Care Management (PCM). This service will provide additional care to patients with a single, serious, chronic condition.  

To qualify for PCM, a 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.   

PCM closely mimics Chronic Care Management (CCM) requirements, and may not be billed concurrently with CCM, behavioral health integration services, monthly capitated ESRD payments and during a surgical global period. Like CCM, a verbal consent is required and must be documented in the patient’s chart. 

A difference is that PCM has a time requirement of 30 minutes a month, verses CCM’s 20-minute requirement. The great benefit to PCM is to provide management for patients with one chronic illness to help navigate and stabilize the condition and the possible prevention of an exacerbation or secondary diagnosis to arise.   

CMS has approved two new G codes to support PCM for CY 2020. 

Non-complex care code. 

30 minutes of physician time per month at $78.68 per patient 

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 patient at risk of hospitalization or have been the 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 
  • RVU of 1.28 for HCPCS code G2064. 

Non-complex care code. 

30 minutes of clinical time per month at $39.70 

Comprehensive care management for a single high-risk disease services, 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 
  • RVU of 0.61 for HCPCS code G2065. 

CMS believes that PCM services describe a situation where a patient’s condition is severe enough to require care management for a single complex chronic condition beyond what is described by CCM or performed in the primary care setting. 

In most cases, a specialist may be the treating provider until the condition is stabilized and returned to the primary care provider. If the patient has only one complex condition that is overseen by the primary care provider, then that provider will also be able to bill for PCM. 

Established Remote Patient Monitoring services could potentially combine their RPM minutes that do not meet the requirements for CCM to maximize reimbursement allowance.  

CMS states, “We are convinced by stakeholders who stated that RPM services are distinct from PCM and could be billed concurrently by the same practitioner for the same beneficiary provided that the time is not counted twice. We will also be monitoring billing of these services. We will appreciate continued input and engagement on these issues with the public and stakeholder community and may make refinements to these policies in future rulemaking. With regard to the relationship between PCM services and HCPCS.”