Understanding Chronic and Principal Care Management Services (CCM vs. PCM)

 

September 29, 2023 | By Grant Huang, CPMA, CPC

If you’ve never heard of principal care management (PCM) or chronic care management (CCM) services before, you’re not alone. Medicare introduced these new benefits for Part B beneficiaries in 2021 and 2022, respectively, but the agency’s own utilization data shows that adoption has been fairly limited.

CMS introduced PCM as a Part B benefit in 2022, and while CCM has been around since 2014, they received new codes and guidelines in 2021 and 2022. CMS utilization data shows low use rates, and the agency has released guidance documents to educate providers and patients, hoping to boost usage. Part of the reason for the slow uptake among practices is the general reluctance by providers to familiarize themselves with multiple time-based codes for once-monthly services. Both CCM and PCM could apply to a patient with multiple conditions that require care from multiple medical specialties, so the need to get patient consent, explain the services, and ensure no other providers on the patient’s care team are also billing them, factors into the difficulty from a provider and practice standpoint.

In this article, we’ll examine the differences between CCM and PCM services as well as which physician specialties are best suited to billing for them. 

Understanding CCM services
CMS launched CCM services in 2014 to try and improve outcomes for patients with multiple chronic conditions that benefit from long-term doctor-patient relationships and often require coordination of care among providers of different specialties. 

Here are three key facts you need to know about CCM services:

1. 1. They are a once-monthly benefit for patients, which means that only one provider will be reimbursed for billing CCM codes per month. This requires coordination with the other providers in the patient’s care team who may potentially be eligible to bill for CCM services. Also, the same provider can’t bill Medicare for both CCM and PCM services for the same patient each month.
   2. They are time-based codes that can be provided by a physician or by clinical staff. The physician reimbursement is about $85 for the first 30 minutes (using a primary code) and an additional $60 per each additional 30 minutes (using an add-on code). CMS sets a medically unlikely limit of 2 units per encounter for the add-on code, which means in most cases the maximum possible reimbursement would be $205 for 90 minutes of CCM services. By comparison, an established patient level 4 code (99214) has a time requirement of 30-39 minutes and would reimburse about $128. These dollar amounts are based on national par rates using the 2023 fee schedule conversion factor.

• They do not require face-to-face visits (unless for a new patient). Unlike regular office visit codes such as 99214, CCM services do not require face-to-face visits. Tasks such as phone calls, updating the patient’s medical record, and discussing the patient’s condition with other providers all count towards the time threshold required to support PCM codes. New patients must first be seen in a face-to-face visit by the provider who “initiates” CCM services.

• Complex CCM services pay more but require MDM. There are two codes for complex CCM services (99487, 99489, see below), and these pay significantly more: $133 for the primary code, $70 for each add-on, with up to 4 add-on units potentially supported. However, these codes require documentation of moderate or high complexity medical decision making (MDM).

6 codes for CCM services

There are six codes for CCM services:

• 99490 (non-complex, staff time, primary code). CCM services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
• 99439 (non-complex, staff time, add-on code). CCM services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
• 99491 (non-complex, physician/QHP time). CCM services, provided personally by a physician or other QHP, at least 30 minutes of physician or other QHP time, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored.
• +99437 (non-complex, physician/QHP time, add-on). CCM services, provided personally by a physician or other qualified health care professional, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, comprehensive care plan established, implemented, revised or monitored; each additional 30 minutes by a physician or other qualified health care professional, per calendar month.
• 99487 (complex, staff time, primary code). Complex CCM services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or substantial revision of comprehensive care plan, moderate or high complexity medical decision making; first 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
• +99489 (complex, staff time, add-on code). Complex CCM services, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, establishment or significant revision of comprehensive care plan, moderate or high complexity medical decision making; each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. 

Documentation requirements for CCM services
To support CCM services, the provider’s documentation (this covers multiple progress notes in the patient’s medical record) must meet the following criteria:

• Show an initiating visit for new patients or patients whom the billing provider has not seen within the past one year; this can be during any separately billed face-to-face E/M visit.
• Show that patient gave consent to receive CCM services; the patient should also be advised that only one practitioner may bill for these services once per month and that the usual Part B cost sharing would apply.
• Show that the patient has at least two chronic conditions that are expected to persist for at least 12 months and that, as a result, the patient faces “significant risk of death, acute exacerbation and or decompensation, or functional decline.”
• Create a comprehensive care plan for these chronic conditions. This plan typically includes:
  • Problem list with expected outcome and prognosis
  • Measurable treatment goals
  • Cognitive and functional assessment
  • Symptom management
  • Medication management
  • Planned interventions
  • Caregiver assessment
  • Interaction and coordination with outside resources, practitioners, and providers
  • Regular review and revision as necessary

CCM services also require giving the patient 24/7 access to providers or clinical staff, including a way for patients or caregivers to contact them to discuss urgent issues at any time of the day.

Understanding PCM services
CMS introduced PCM services in 2020 to improve reimbursement for providers handling complex and enduring diseases. It was hoped that this could direct greater reimbursement to those specialties and providers who were doing the most to tackle the most difficult problems represented by E/M services, as opposed to simply boosting E/M payment across the board – an expensive and imprecise option.

Here are three key facts you need to know about PCM services:

1. 1. They are meant to manage a single high-risk disease that is expected to last at least 3 months and up to 12 months (or until the death of the patient). To qualify, the disease must place the patient at significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or even death.
   2. They are a once-monthly benefit for patients, which means that only one provider will be reimbursed for billing PCM codes per month. This requires coordination with the other providers in the patient’s care team who may potentially be eligible to bill for PCM services.
   3. They are time-based codes that can be provided by a physician or by clinical staff. The physician reimbursement is about $83 for the first 30 minutes (using a primary code) and an additional $60 per each additional 30 minutes (using an add-on code). CMS sets a medically unlikely limit of 2 units per encounter for the add-on code, which means in most cases, the maximum possible reimbursement would be $206 for 90 minutes of PCM services. By comparison, an established patient level 4 code (99214) has a time requirement of 30-39 minutes and would reimburse about $130. These dollar amounts are based on national par rates using the 2022 fee schedule conversion factor.

• They do not require face-to-face visits. Given how much more 99214 pays for the same amount of time spent, it might seem that PCM codes don’t make much financial sense. However, the crucial advantage of PCMs services is that they do not require a face-to-face visit. Tasks such as phone calls, updating the patient’s medical record, and discussing the patient’s condition with other providers all count towards the time threshold required to support PCM codes.

Coding and billing rules for PCM services
To support a PCM code, the provider’s documentation must meet the following criteria as stated in the 2022 and 2023 CPT manuals:

• Show (somewhere in the patient’s medical record) that patient gave consent to receive PCM services; the patient should also be advised that only one practitioner may bill for these services once per month and that the usual Part B cost sharing would apply.
• Show that the patient has at least one complex chronic condition that is expected to persist for at least three months and that this condition places the patient “at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, death.”
• Show that the condition in question requires development, monitoring, or revision of a disease-specific care plan.
• Show that the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
• Show that there is ongoing communication and care coordination between relevant practitioners furnishing the patient’s care.
• Show that the minimum time requirements are met (a full 30 minutes for each code).

The codes involved are:

• 99424 for the first 30 minutes of PCM time spent by a physician or other qualified healthcare professional (QHP);
• +99425 for each additional 30 minutes of PCM time spent by a physician or other QHP;
• 99426 for the first 30 minutes of PCM time spent by clinical staff under the direction of a physician or other QHP; and,
• +99427 for each additional 30 minutes of PCM time spent by clinical staff under the direction of a physician or other QHP.

Because PCMs don’t require face-to-face time and can be billed by non-physician practitioners using the clinical staff codes, they don’t really increase your administrative burden, apart from the documentation requirements. Incident-to rules would apply if the NPPs try to bill using the physician/QHP codes because PCMs are considered E/M services, but even without incident-to, the clinical staff codes offer reimbursement for work that is already being done in most cases.

Key differences
Having covered the guidelines for these two types of services, here’s the bottom line list of differences between CCM and PCM:

• CCM requires at least two chronic conditions to be managed, PCM only requires one.
• CCM codes are more complicated because some codes require medical decision-making (MDM) in addition to time.
• CCM can involve managing transitions of care as well as preventive care, which are tasks better suited to primary care providers.
• Conditions managed via PCM are expected to last 3-12 months, while conditions managed via CCM are expected to last at least 12 months.
• PCM is better suited for specialists who are the focal point for managing a particular disease, such as endocrinologists engaged in long-term management of a patient’s thyroid disease or rheumatologists doing the same for a patient’s rheumatoid arthritis.
• PCM is also appropriate for specialists assuming care for an acutely exacerbated complex chronic condition, one that presents a significant need for hospitalization, high risk, and threat to life, for the expected 3-12 month timeframe.
• A patient may not receive both CCM and PCM from the same provider each month, so individual providers must choose one service type for a patient and stick with it (after obtaining patient consent).

For more information, check out CMS’ guide to CCM and PCM services on the Medicare Learning Network: www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf.

Your next steps:

1. Expand your compliance knowledge! Check out the agenda for the 15^th Annual NAMAS Auditing & Compliance Conference and register to attend!
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