Chronic Care Management (CCM) vs Principal Care Management (PCM) Key differences and scope of care
PCM was added to CMS as a Part B benefit in 2022, and CCM has been in existence since 2014 but got new codes and guidelines in 2021 and 2022. The data on the use of CMS are provided, and according to them, the rates of utilization remain low; the agency has issued guidance documents to increase the usage among providers and patients.
The provider’s prevailing reluctance to become familiar with the multiple time-based codes for once-monthly services contributes to the delayed practice adoptions. Both CCM and PCM could relate to a patient who has multiple disease states that need care from different specialties; hence, the process of getting consent from the patient, explaining to the patient about the services, and ensuring that no other provider in the patient’s care team is billing the patient are some of the factors that make the process difficult from the provider and practice perspective.
In this article, we will explain what the key differences are between CCM and PCM services and which medical specialties are most appropriate for billing them.
What is Chronic Care Management?
A chronic patient care framework is called chronic care management. It significantly contributes to better patient care. It includes ongoing counseling, support, and patient assessment in addition to clinical visits.
Assisting patients to better manage their chronic illnesses is the primary objective of CCM. Chronic illness conditions include heart disease, cancer, stroke, diabetes, renal disease, chronic respiratory disorders, septicemia, pneumonia, influenza, Alzheimer’s disease, and post-injury recovery. In the CCM program, a healthcare provider analyzes the condition of the patient, provides a treatment plan for the patient’s healthy lifestyle, and also provides directions.
What is Principal Care Management?
CMS introduced a new care model known as principal care management in 2020 to offer further care to patients with one chronic disease. This was developed to fill the void that was created by CCM treatment for patients with only one chronic condition.
Another objective of PCM is to target the patient’s chronic disease as soon as possible and offer appropriate intervention to manage it to the extent that they can be returned to their primary care physicians. This decreases the patient’s healthcare costs and leads to better patient outcomes.
Differences Between CCM, PCM, and Their Scope of Care
CCM Services:
Assessments and updates regularly on the patient’s treatment plan according to the changing patient’s health conditions and needs.
Making sure that all the prescribed medicine is handled properly and does not negatively interact with one another.
Providing patients with all the information and resources to make them aware of their health conditions to make wise health decisions.
Addressing behavioral health concerns that may accompany chronic physical conditions.
Make sure that the patients have access to social services that will assist them in getting the services they need to support their health, for instance, housing, transport, and financial support.
PCM Services:
Careful monitoring of the patient’s health with regular adjustments to the treatment plan and medications as required.
Coordination with medical specialists in the management of the specific chronic illness condition and transitional care management.
To guarantee adherence to the care plan and handle any issues or complications that may occur, regular contact is necessary with the patient and their caregivers.
Giving proper education on how to manage specific chronic conditions, symptom management, and lifestyle modifications, and making them aware of when they need medical attention.
Creating a plan to deal with any acute episodes or exacerbations of the chronic illness, including knowing when to go to the emergency or make doctor’s appointments.
Key Facts Regarding Chronic Care Management (CCM) Services:
Exclusive Billing for CCM Services:
It is a monthly service for patients and as such, only one provider can be reimbursed for billing the CCM codes in a given month. This involves communication with the other providers in the care team who may be able to bill for CCM services. Moreover, it is unlawful for one provider to bill Medicare for both CCM and PCM services for a patient in the same month.
CCM Code Classification and Reimbursement:
They are codes that are classified based on time and can be given by a physician or clinical staff. The physician reimbursement is about $85 for the first 30 minutes with a primary code and $60 for each subsequent 30 minutes with an add-on code. CMS has set a very stringent limit of 2 units per encounter for the add-on code and thus in most circumstances, the maximum possible reimbursement that can be obtained would be $205 for 90 minutes of CCM services. On the other hand, an existing patient level 4 code (99214) includes a time frame of 30-39 minutes, and the amount of reimbursement will be $128.
Service Requirements:
They do not have to involve personal contact with the patient (except when the patient is new to the practice). CCM services do not include face-to-face visits, which are the basis for codes like 99214. Telephone conversations, writing notes in the patient’s record, and consultation with other practitioners also contribute to the time limit that needs to be met to support PCM codes. New patients are required to have an in-person visit from the provider who initiates CCM services.
Complex CCM Services:
Complex CCM services require MDM but they pay more. There are two codes for the complicated CCM services that pay much more: $133 for the primary code and each add is $70 and it supports 4 more add-on units. These codes require documentation of the moderate or high complexity medical decision-making (MDM).
Key Facts Regarding Principal Care Management (PCM) Services:
Eligibility Criteria:
They are intended to treat a single, high-risk illness that lasts from 3 months to up to 12 months. For this, the disease must put the patient at high risk for hospitalization, exacerbation/decompensation of the disease, worsening of the functional status, or death.
Billing and Coordination for PCM Services:
Patients can only receive benefits once a month which means that only providers will get the payment for billing codes each month. Coordination with the other healthcare professionals on the patient’s care team is a must to bill for PCM services.
PCM Code Classification and Reimbursement:
They are time-based codes that can be billed by a physician or by clinical staff. The reimbursement for the physician is $83 for the initial 30 minutes through the use of the primary code and $60 for every other 30 minutes through the use of an add-on code. CMS limits the add-on code to 2 units per encounter, which in most cases, the highest possible fee schedule amount would be $206 for 90 minutes of PCM services. Conversely, an existing patient level 4 code (99214) has a time component of 30-39 minutes and will be paid approximately $130.
Service Requirements and Benefits:
They do not involve physical visits, which means that one does not have to travel to another person’s house to make a presentation. Because 99214 pays so much more for the same amount of time, one might initially assume that PCM codes are not financially beneficial. However, the important benefit of PCM services is that they can be provided without a face-to-face visit. Telephonic conversations, updating the patient record, and consultation with other providers are examples of activities that can help to meet the time requirements for PCM codes.
To get in touch call us right now at (713)715-7997 to learn more about our CCM services or you can also book a 30 min free consultation.
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