Learn what Principal Care Management (PCM) is, who qualifies, how it differs from CCM, and how Medicare billing works with PCM CPT codes.
When providers care for patients with a single, serious chronic condition, they invest significant time outside of routine visits - adjusting medications, updating care plans, coordinating follow-ups, and monitoring for complications. Principal Care Management (PCM) is the Medicare program that reimburses for the work. Understanding what PCM means, who qualifies, and how billing works helps practices capture revenue they are already earning.
What Is Principal Care Management (PCM)?
Principal Care Management is a Medicare Part B program introduced by the Centers for Medicare & Medicaid Services (CMS) to reimburse clinicians for managing a patient's single, high-risk chronic condition between face-to-face visits. Unlike Chronic Care Management (CCM), which targets patients with two or more chronic conditions, PCM focuses specifically on one complex condition that demands ongoing, disease-specific attention.
PCM covers services such as:
- Developing and updating a disease-specific care and treatment plan
- Medication management and adjustment
- Patient follow-up and care coordination
- Monitoring for acute exacerbation, decompensation, or functional decline
- Communication with other treating providers involved in the patient's care
To understand how PCM compares to CCM in terms of eligibility and billing requirements, see our CCM services guide.
Who Qualifies for PCM?
Not every patient with a chronic condition qualifies. CMS has defined specific eligibility criteria that must be documented before enrollment.
Patient eligibility requirements:
- Has one chronic condition expected to last at least three months or until the end of life
- The condition places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death
- Written or verbal consent must be obtained and documented
- A face-to-face initiating visit must occur prior to the first billing month
Provider eligibility:
PCM may be billed by physicians, qualified healthcare professionals (QHPs), nurse practitioners, physician assistants, and clinical nurse specialists. Clinical staff may also deliver PCM services under the direct supervision of a physician or QHP.
PCM CPT Billing Codes (99424–99427)
CMS replaced the original HCPCS codes (G2064 and G2065) in 2022 with four dedicated CPT codes for PCM. These codes are split between provider-delivered and clinical staff-delivered services.
Provider/QHP codes:
- CPT 99424 - First 30 minutes of PCM per calendar month, delivered by a physician or QHP. Includes developing a disease-specific treatment plan. Reimburses approximately $83/month.
- CPT 99425 - Each additional 30 minutes of provider time in the same month. Reimburses approximately $60 per increment.
Clinical staff codes (under physician supervision):
- CPT 99426 - First 30 minutes of PCM delivered by clinical staff, directed by a physician or QHP. Reimburses approximately $72/month.
- CPT 99427 - Each additional 30 minutes of clinical staff time per month. Reimburses approximately $48 per increment.
Only one set of codes applies per patient per month - either 99424/99425 (provider) or 99426/99427 (clinical staff), not both. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) should bill using HCPCS code G0511 instead of individual CPT codes, per the CMS Medicare Physician Fee Schedule care management page.
PCM vs. CCM: Key Differences
A common source of confusion is whether to enroll a patient in PCM or CCM. The distinction comes down to the number of chronic conditions and which provider is managing them.
Importantly, PCM and CCM cannot be billed by the same provider for the same patient in the same month. However, a primary care physician may bill CCM for one set of conditions while a specialist bills PCM for a single high-risk condition - as long as the conditions are different and separate care plans exist.
Billing Requirements and Compliance Tips
Accurate billing for PCM requires consistent documentation each month. Before submitting a claim, providers should confirm:
- At least 30 minutes of qualifying time have been logged for the billing month
- Patient consent is documented and renewed annually
- The initiating face-to-face visit has occurred (required once per year for continued enrollment)
- The ICD-10 diagnosis code for the qualifying chronic condition is included on the claim
- No conflicting or duplicate care management codes have been submitted for the same patient and month
Medicare Part B covers 80% of the PCM benefit, with patients responsible for the remaining 20% co-pay. Practices should ensure patients are informed of this cost-sharing structure at enrollment.
How PCM Fits Into a Broader Care Strategy
PCM works best as part of a layered care approach. Patients receiving PCM for one high-risk condition may simultaneously benefit from Remote Patient Monitoring (RPM), which provides real-time data on vitals and health trends between visits. This combination supports more proactive clinical decision-making and reduces the risk of avoidable hospitalizations - the very outcome PCM is designed to prevent.
As CMS continues to expand reimbursement pathways for non-visit care, PCM represents a meaningful opportunity for practices to align clinical resources with patients who need the most focused attention - and to be appropriately compensated for delivering it. Practices that have not yet implemented PCM often find that a significant portion of their eligible patient panel is already receiving these services informally, without billing. Conducting a panel review, establishing documentation workflows, and confirming billing compliance before scaling enrollment is the most practical path to launch.
Conclusion
Principal Care Management (PCM) helps providers deliver structured, ongoing support for patients with a single high-risk chronic condition while receiving reimbursement for non-face-to-face care activities. By improving care coordination, medication management, and disease-specific monitoring, PCM supports better patient outcomes and reduces the risk of complications and hospitalizations.
As healthcare continues to shift toward value-based care, PCM offers practices a practical way to enhance patient care while capturing appropriate Medicare reimbursement for services they are already providing.
Frequently Asked Questions
Q1. What does PCM stand for in medicine?
PCM stands for Principal Care Management. It is a Medicare program that reimburses providers for managing a patient's single high-risk chronic condition through care planning, medication management, and care coordination.
Q2. How is PCM different from CCM?
PCM is designed for patients with one complex chronic condition, while CCM is for patients with two or more chronic conditions. PCM requires at least 30 minutes of care per month, compared with 20 minutes for standard CCM.
Q3. Which CPT codes are used to bill PCM?
PCM uses CPT codes 99424 and 99425 for physician or QHP services, and 99426 and 99427 for clinical staff services under supervision. RHCs and FQHCs use HCPCS code G0511.
Q4. How much does Medicare reimburse for PCM?
Reimbursement varies by location and code. Generally, CPT 99424 pays about $83 per month, while additional PCM service codes provide extra reimbursement based on time spent.
Q5. Can a patient receive both PCM and CCM at the same time?
Yes, but not from the same provider for the same condition. A specialist may bill PCM for a high-risk condition while a primary care provider bills CCM for separate chronic conditions.
Q6. Does the patient need to give consent for PCM?
Yes. Written or verbal patient consent must be obtained and documented before PCM services begin. Consent should also be renewed annually for continued participation.