Principal Care Management (PCM) 2026: CPT Codes, Workflows & Medicare Updates

Medicare’s recent efforts to embrace value-based care have resulted in a trend toward reimbursing healthcare providers who improve patient outcomes while limiting unnecessary healthcare costs. Principal Care Management (PCM) is one of the emerging programs to support this movement by providing a care coordination service for Medicare beneficiaries with one serious, high-risk chronic condition.

The key difference between PCM and other care coordination programs is PCM’s targeted focus on the management of a single complicated condition that requires routine clinical oversight, such as advanced heart failure, uncontrolled diabetes, or severe COPD.

The Centers for Medicare & Medicaid Services (CMS) introduced PCM in 2020 to resolve a gap in care. Many beneficiaries have one chronic condition that predominates their healthcare needs when properly managed, resulting in fewer hospitalizations, ER visits, slow disease progression, etc.). Therefore, PCM was introduced because Medicare saw that there was no need for Chronic Care Management (CCM) that covers multiple conditions for the patient, but there was still a need for ongoing clinical support, medication oversight, and care coordination; thus, PCM was created to fill the gap, and patients with a single high-priority, current condition could receive structured, proactive management.

What is Principal Care Management (PCM)?

Principal Care Management (PCM) is a Medicare-covered care coordination service that is meant for patients, either inpatient or outpatient, who have one serious high-risk chronic condition requiring regular clinical oversight and ongoing management.

PCM is not a chronic care program, which focuses on a broader set of chronic conditions. It addresses the most significant health issue for the patient, i.e. a chronic condition that is most likely to have complications, increase hospital utilization, and decrease the patient’s quality of life.

The CMS defines PCM as a service for beneficiaries with:

• One complex chronic condition expected to last at least three months (though often much longer).
• A condition that places the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
• A need for frequent adjustments to treatment and coordination of care.

It is designed for situations in which a single diagnosis drives most of a patient’s needs. Although there is no prescription list, PCM applies to conditions such as:

1. Congestive Heart Failure (CHF): requires continuous monitoring to ensure the risk of hospitalization is reduced.
2. Chronic Obstructive Pulmonary Disease (COPD): prone to acute exacerbation.
3. Uncontrolled Diabetes Mellitus: medication adjustments made frequently.
4. Late-stage Kidney Disease: require constant coordination of care.
5. Advanced Cancer: involves ongoing treatment and symptoms management.

The Expansion of the Role of PCM in the US Healthcare System

According to the Centers for Disease Control and Prevention (CDC), nearly 60% of Americans have at least one chronic disease with nearly 66.50% of Medicare spending on dealing with it. A sizable portion of these individuals have a single primary condition as the main driver for their health-related risks and overall costs, while PCM is a critical intervention for this population.

As a service bundle, PCM has been particularly effective at:

• Reducing hospital readmissions in patients just recently discharged after acute events impact their underlying chronic illness.
• Improving medication adherence from regular follow-up/support by phone or video and education.
• Engagement with patients with regular follow-ups and through one single plan.

Essential Components of a Successful PCM Program for Providers

PCM involves more than only occasional follow-up. If a provider seeks to bill Medicare for PCM services, the provider must deliver an organized management of care that includes:

1. Comprehensive Care Plan: A comprehensive care plan is a foundational element of Medicare’s principal care management and should be developed, implemented and reviewed periodically to ensure that the plan reflects the patient’s current health condition. It includes specific goals, interventions, and responsibilities needed to manage the single chronic condition and needs to be shared with the patient, their caregivers and other treating providers to ensure they are on the same page as to what treatment path to follow.
2. Ongoing Care Coordination: PCM is the continued coordination between the primary provider and other healthcare professionals participating in the patient’s treatment. It requires periodic and continuous communication with specialists, diagnostic labs, and imaging centers. Providers must ensure that additional tests or imaging records are compliant with the comprehensive care plan; so that no duplications, no delays and no unnecessary costs are incurred unnecessarily.
3. Management of Medications: Management of medications is part of PCM. Provider reviews all of the patient’s active transmitted prescriptions, for effectiveness and safety. This review will be centered on any potential interactions, accuracy of dosage, and patient’s tolerance of the medication. Providers also assess any potential side effects as well as barriers to use that would impede the patient from taking the prescribed medications and suggesting alternatives when possible to increasing adherence.
4. Communicating with the Patient and Caregivers: Frequent and meaningful contact with patients can help them feel supported and informed. This can be done by phone, secure patient portal, and face to face video interaction. Providers are also providing ongoing education that ensures better awareness for patients and caregivers pertaining to their chronic conditions, treatment expectations, and self-management techniques, thereby leading to improved health outcomes.
5. Documenting and Billing Compliance: Accurate and complete documentation and billing are essential for Medicare payment and program integrity. Providers are responsible for tracking, recording and accounting the time spent on PCM, which must comply with the minimum threshold of 30 minutes per month of PCM time. In addition, all required elements defined by CMS must be documented, which will help demonstrate compliance in future audit and avoid claims denials.

Who Can Provide PCM Services in 2026?

PCM services can be billed by Medicare-approved providers such as:

• Physicians (MD, DO)
• Nurse Practitioners (NP)
• Physician Assistants (PA)
• Clinical Nurse Specialists (CNS)

What Are the PCM CPT Codes for 2026?

In the Principal Care Management category of the Medicare Physician Fee Schedule (MPFS), the Centers for Medicare & Medicaid Services (CMS) replaced the former PCM codes (HCPCS codes G2064 and G2065) with four new CPT codes.

PCM codes are divided into two main categories:

• Physician or Qualified Healthcare Professional (QHP) Codes (CPT 99424 and CPT 99425) – for providers directly managing the care programs. 
• Clinical Staff Codes (CPT 99426 and CPT 99427) – for care provided by nurses or other staff under direct supervision.

All of these codes are based on compensating physicians for the extra work they complete in caring for high-risk complex chronic illnesses. This includes medication changes, developing a whole care plan, patient follow-up, and much more.

• CPT Code 99424:  CPT Code 99424 is inclusive of the first thirty minutes of PCM services per calendar month, counting the physician’s or qualified healthcare professional’s compilation of a disease-specific care plan and treatment plan. CPT code 99424 is a continuation of the services previously provided by G2064.

The providers who can bill under CPT Code 99424 include physicians, qualified healthcare professionals, advanced practitioners, physician assistants, and nurse practitioners.

2025 National Average Reimbursement: $84–$88

• CPT Code 99425 : CPT code 99425 is for each additional thirty minutes the physician or qualified healthcare professional performs in a calendar month. This is often maybe continuous and with some of it related to primary care management, but for most patients it also works into the proactive medication management aspect of a patient.

Eligible providers to bill under CPT Code 99425 include medical doctors, qualified health care professionals, and advanced practitioners, PAs or NPs.

2025 National Average Reimbursement: $60–$65.

• CPT Code 99426: CPT Code 99426 is described as the first 30 minutes of PCM clinical staff time as provided by clinical staff under the supervision and direction of a physician or qualified health care professional. CPT Code 99426 is an extension of the prior G2064 and with the inclusion of 99427.

CPT Code 99426 enables billing practitioners (a clinical professional or nurse) employed under the direct supervision of a physician or qualified health care professional, like a PA or NP.

2025 National Average Reimbursement: $62–$66.

• CPT Code 99427 : CPT Code 99427 is for each additional 30 minutes of PCM clinical staff time as provided by clinical staff and nurses under the supervision and direction of a physician or qualified health care professional.

Clinical professionals, nurses, qualified health care professionals (QHPs), advanced practitioners, PAs or NPs are eligible billing practitioners for CPT 99427.

2025 National Average Reimbursement: $44–$48.

(Note: The reimbursement rate varies for different locations)

Time Tracking Requirements for Billing PCM Codes

Medicare has strict expectations when billing these time-based codes. To bill the PCM:

• All time must be documented in the patient’s medical record.
• All activities that are counted towards a PCM have to relate to the patient’s one chronic condition.
• The time can be cumulative over the month, and doesn’t have to be consecutive.

Eligibility Criteria for Billing PCM Codes for Providers

Providers need to ensure the following before billing for PCM:

1. One Complex Chronic Condition – A single chronic condition expected to last at least or more than 3 months and significantly affecting the patient’s health.
2. Patient Consent – There is verbal or written patient consent and it is recorded in the medical record.
3. Only One Provider Can Bill PCM in a Month – No double billing for one patient with multiple practices.
4. No Overlap with CCM Codes – You cannot bill for PCM and CCM for the same patient in the same month.

Key Billing Updates For Principal Care Management (PCM) in 2026

• Slight Payment Rise- Providers will witness a rise in reimbursements for PCM codes compared to 2025 due to Medicare Physician Fee Schedule adjustments.
• Telehealth Flexibility– PCM services may be furnished via telehealth under current CMS waivers, though this could change in future rulemaking.
• Emphasis on care plan sharing– CMS is increasingly stressing that the patient and all care team members must have access to the care plan.

What You Must Do to Avoid Overlap Rules & Concurrency

• No double-billing for the same service/time: Time counted for PCM cannot be used to bill CCM, RPM interpretation, or other time-based codes for the same minutes. For example, a 30-minute clinical-staff phone that is billed to PCM (99426) cannot simultaneously be applied to CCM (99490) for those same 30 minutes.
• One provider bills PCM per month per patient: If a specialist bills PCM for a patient, another provider should not bill PCM for that same patient and month.
• Programs can complement each other if distinct: PCM + RPM is a common and compliant combination. RPM captures day-to-day physiologic data; PCM clinicians use that data to update the condition-specific care plan and coordinate care.
• TCM is short windows; PCM is ongoing: If a patient is in a TCM window after discharge and also meets PCM criteria, carefully separate tasks: TCM covers transitional visits and coordination tied directly to discharge, while PCM covers broader ongoing disease management in that month, only bill both if distinct services and time are documented.

Documentation Guidelines to Avoid Reimbursement Denials

1. Always mention the principal condition in each PCM note, and associate every activity/area to that principal condition.
2. Keep timestamps on your time entries and add the monthly minutes/total for these PCM codes and any RPM/CCM minutes separately in the notes.
3. Save the ongoing care plan with measurable goals for the patient’s conditions and specific interventions related to your PCM efforts.
4. Document consent for PCM (verbal or written) and for each RPM device you have the patient use.

For example: For a patient with advanced heart failure requiring weekly diuretic adjustments with daily weight, a healthcare provider would bill PCM for coordination focused on the condition (99426/99427) and RPM codes for device data and monitoring, recorded separately for both.

Common PCM Billing Pitfalls and How to Avoid Them

1. Inaccurate Time Documented: Use reminders in EHR or a structured documentation log that document minutes dedicated to patient care specifically.
2. Inadequate Care Plan Documented: Care plans must be thoroughly completed and documented in the medical record, sometimes including the care plan in clinical notes as necessary. Also, they should also be updated monthly.
3. Missing Patient Consent: Ensure patient consent is documented either in a visit or scheduled telephone consult in the patient’s medical record: date, consent, method, confirmation either by phone/visit.
4. Duplicating Charges with CCM or TCM: Consider maintaining records on an individual’s condition. Do not bill PCM and CCM or TCM on the same patient and time period unless you can document and illustrate why both services are relevant.
5. Incorrect Place of Service or Modifiers: Always bill for services at the appropriate place and for modifiers if applicable based on CMS guidelines.

Tips to Maximize Your CMS Reimbursements for A PCM Program

If providers can achieve fluency with PCM billing procedures, time tracking, documentation, and compliance, they can deliver high-value care, for specific conditions, while accurately getting all of the Medicare reimbursements they are entitled to.

1. Identify high need patients early, especially those who are recently discharged from a hospital or those who have newly discovered unstable conditions.
2. Consider bundling remote patient monitoring (e.g., RPM for vital signs) with PCM, which can create improved outcomes and better services to payers.
3. Implement structured workflows for PCM to ensure a more consistent and quality-focused product for patients, but also to be ready for an audit.
4. Perform an audit on PCM claims quarterly to identify documentation weaknesses before it leads to a denied claim.

How Does a PCM Program Work Step-by-Step? 

To ensure successful delivery of Principal Care Management services under U.S. Medicare regulations, it takes a lot more than just assigning billing codes. It takes a process that is structured and repeatable and withstands compliance audits, enhance patient outcomes, and ensure proper reimbursement.

Here’s a step-by-step operational model for health systems and providers for maximum benefits:

Step 1: Identify Patients & Verify Eligibility

This step involves identifying Medicare beneficiaries who meet PCM eligibility requirements. To do so, consider the following:

1. EHR Query & Reporting – Utilize your electronic health record (EHR) clinical data to query the following patients with one chronic condition that:

• • Exists for at least 3 months
  • Carry the risk of hospitalization, functional decline, or death.
  • Requires the continuous supervision of care coordination.

2. Identify Referrals from Specialists & PCP’s– Work with specialists or primary care physicians who are active professionals managing these conditions (e.g., oncologists, cardiologists, endocrinologists).

3. Verify Eligibility – To ensure the eligibility criteria is met:

• • The patient must have one significant chronic condition, not multiple (if the patient has multiple conditions, the patient may be eligible for CCM).
  • The condition is in the chronic condition list with ICD-10 coding.
  • The patient has Medicare Coverage under Part B.

Step 2: Patient Consent & Education

To enroll a patient in a PCM program, a provider must document and receive the patient consent and set expectations. Top actions to take include:

1. Verbal or Written Consent: Documentation in the medical record is required and CMS allows both verbal and written method for getting the patient consent.

2. Descriptive Statements: A provider must understand what PCM is and guide the patient about the program:

• • What Principal Care Management services are?
  • Pay a 20% coinsurance if you don’t have supplemental coverage.
  • Only one practitioner can bill for PCM in a given month for a patient.

3. Documentation: Record when consent was obtained, including the method of consent, and patient understanding in the care plan.

Step 3: Comprehensive Assessment & Care Plan Development

This step focuses on conducting a comprehensive assessment and care plan development for problem-focused care related to the mentioned chronic condition. Key actions to take include:

1. Comprehensive Review: Conduct a thorough review of-

• • Current lab reports, imaging, test results
  • Medication adherence and side effects
  • Social Determinants of Health (SDOH) that impact the condition.

2. Setting Goals: Work with the patient to set measurable goals (e.g., “A1C to be reduced to less than 7% in 6 months for diabetes”).

3. Care Plan: A result-oriented care plan must focus on:

• • Diagnosis and ICD-10 code(s)
  • Interventions for plan of care
  • Members of the care team to which the responsibilities will go
  • Instructions for patient self-care activities.

4. Share Care Plan: Send a copy of the care plan to the patient either electronically or by mailing a hard copy.

Step 4: Monthly PCM Service Delivery

Provide a minimum of 30 minutes of non-face-to-face care coordination and management during a calendar month. Some key actions to take include:

1. Non-Face-to-Face Care Management– This may include:

• • Medication Therapy Management (MTM)
  • Coordinating care with any specialists related to the patient’s health
  • Reviewing test results and possibly altering treatment according to results
  • Scheduling follow-up appointments
  • Educating the patient, and advising on self-monitoring

2. Time Tracking – Whether you are using the stopwatch feature in your EHR or a manual log, the important part is tracking your cumulative time on a monthly basis.

3. Care Team Collaboration – Document your communications with care team members, including your notes and/or notes from care coordinators and/or nurses.

Step 5: Documentation for Compliance

This step focuses on keeping clear records that will prepare you for an audit. The required documentation includes:

1. Date of patient consent and how it was documented.
2. Particular diagnosis and assigned ICD-10 codes.
3. Care plan with measurable goals as outlined in the PCM activity.
4. Detailed records of non-face-to-face services that were performed.
5. People and roles of the members of the care team involved in the coordination or management.
6. Total time spent (≥30 minutes) during the month.

Step 6: Medicare PCM Billing Process

This step covers submitting the accurate claims activities in order to obtain maximum reimbursement. The PCM CPT Codes commonly billed by providers include:

1. G2064 – Physician or other qualified health care professional PCM services, 30+ minutes of services in the last month -in calendar month.
2. G2065 – Clinical staff PCM services, directed by a physician or other qualified health care professional, 30+ minutes of services in the last month -in calendar month.

Before you compile the billing, make sure you:

• Bill only one time per patient per month per provider
• Do not bill the same patient for PCM and CCM in calendar month by same provider
• Include appropriate ICD-10 code for patient’s chronic illness

Step 7: Quality and Audit Ready

After billing is done, maintain compliance quality assurance and enhance the effectiveness of your PCM program. Focus on:

1. Monthly Internal Audits – Randomly pick a few PCM charts to ensure the documentation of all elements is present.
2. Staff Training – Recurrent training of billing staff and care coordinators to ensure compliance with PCM documentation standards, as well as billing and other rules.
3. Performance Metrics – Tracking hospital readmissions, ER visits, patient satisfaction, etc., are all good indicators of program mitigation and overall impact.
4. Audit Ready – PCM documentation should always be easily located or retrieved to ensure we can meet a 24-hour audit request.

What Compliance & Audit Readiness Steps Are Essential?

To deliver successful Principal Care Management services under Medicare, it is more than just expertise; it requires proper documentation, well-designed workflows, and auditable activities. Here’s why compliance is important in PCM:

• Audits from Medicare have recently been raised around PCM and other care management codes.
• Claims denials and financial risk can rise due to documentation that is incorrect or inadequate.
• Documenting compliance insulates the practice in terms of credibility with payers and regulators.

4 Pillars of Compliance for Audit Readiness in PCM

To ensure you are always compliant with the billing and reimbursement processes, here are the pillars of audit readiness you must meet:

1. Documentation of Patient Consent

• Must include date, method of consent (verbal or written), and how the patient was informed of the services to be provided, for which costs are to be incurred, and how to opt out if desired.
• All documentation should be stored in the patient’s record but can be stored in metadata (if available) so it can be easily retrieved.

2. Timely and Accurate Care Plan

• Care plan should only relate to the patient’s single chronic condition and should be updated regularly.
• It should include patient goals, planned interventions, self-management strategies and next review date.
• It must be easily available to the care team and easily identified as a “PCM Care Plan.”

3. Time Tracking Integrity

• Track exact minutes of PCM activities monthly (in 30-minute increments).
• If both the physician and clinical staff time are included, you should separately document each.
• Use a digital timer that syncs with the care plan or a log with timestamps to prevent rounding errors.

4.Billing & Claim Documentation

• Make sure the appropriate PCM CPT Code matches the time spent documented.
• Include the proper diagnosis (ICD-10 code) consistent with the condition for the PCM.
• Keep a clean tracking sheet for all submitted claims to the payer and their allowed amounts; frequently reconcile the tracking sheet.

Regulatory Updates and Ongoing Monitoring

With disciplined workflows, consistent and robust documentation, and internal audits, your PCM program will not only provide improved patient care, but it will be the same in compliance and consistency.

• CMS alters PCM billing rules annually; we recommend checking annually with the Medicare Physician Fee Schedule (PFS) release.
• Changes to telehealth allowances (especially after COVID) are on the horizon.
• In the future, it’s worth following new developing programs, like the Behavioral Health PCM or larger CMS initiatives for Advanced Patient Care Management (APCM).

What Technology Supports PCM in 2026?

Although Principal Care Management is a clinical service, we think the future of PCM could be dependent on the technologies that are available. The long-term commitment to PCM will be challenging if a practice hasn’t implemented the significant technology needed to ease the workload associated with time-tracking, documentation, billing, and following up with patients otherwise taking the majority of the staff time and effort while being neither fun nor profitable.

Every innovative PCM program uses a technology platform aligned with the needs of care management, made use of Electronic Health Record (EHR) technology, and designed workflows around how the practice could implement them consistently, admirably, and profitably.

The key problems that a PCM program faces, include care coordination, complete billing documentation, and patient monitoring are exactly where technology has the ability to provide leverage support. Providers can:

• Automate time-consuming tasks, such as tracking time and documenting consent for services.
• Centralize patient information so that the team can view the same patient, at the same time.
• Support proactive care by providing real-time alerts, reminders, and monitoring.
• Use billing workflows with audit-ready reports.

More significant patient engagement leading to better clinical outcomes ensures a continuous revenue stream supported by Medicare reimbursement.

What Features Should Providers Look for in a PCM Platform?

Standalone or integrated PCM platforms deliver some unique options that are specifically designed for care management, such as:

1. Automated Time Tracking: Every engagement, including phone calls, chart reviews, and care plan updates is tracked for date/time and automatically documented as completed. No chance of manual logging errors or non-compliance with Medicare’s 30-minute minimum requirement.
2. Dynamic Care Plan Management: Providers can create dynamic care plans that are personalized to reflect a single chronic condition for the patient and continuous updates and sharing are simple. Progress notes and interventions are included directly in the care plan to promote transparency and real-time documentation of the patient’s change of condition, clinical response to intervention, and care management.
3. Ability for Secure Communication: HIPAA-compliant messaging, video calls and patient portals help to ensure easy and documented communication between patient and care teams, including doctor, nurse or social worker.
4. Ability for Consent Capture: Digital signature workflows provide patient consent in these situations, as client agreement is collected in real-time and forms stored in the patient’s electronic record to evidential audit.
5. Ability for Billing Integration: Some platforms will generate CPT-specific reports based on what has occurred with the patient, that then map directly onto claim submissions to decrease time for administration and cost of administrative back and forth with payers.

PCM Workflow Optimization for Security & Compliance 

It is not just the technology that will lead to success; the key is how the technology is applied. Successful, high-functioning PCM programs need the following:

• Clarify roles – Clinical staff does the routine check ins/data collection, while providers focus on high-value interventions.
• Tier the patient’s engagement – Engage those patients needing more touch points with scheduled outreach, while meeting time thresholds/wellness visits without overloading providers.
• Easily schedule repeated tasks – Reminders of missed calls, overdue care plan updates, or unbilled time based on built-in platform reminders.
• Embedded analytics dashboards – Identify barriers to provider engagement and missed documentation, billing readiness, and pulling reports on revenue outcomes, without a compile time.

How Does PCM Integrate with RPM?

While PCM introduces and makes use of home health devices, including cellular medical devices, such as BP monitors, pulse oximeters, glucose meters to provide clinical data to the patient care team, which:

• Creates opportunities to intervene prior to a medical condition deteriorating.
• Creates potential for additional billing for RPM services (99453, 99454, 99457 etc).
• Enhance care plans with objective patient data.

There is clearly sync between PCM and Remote Patient Monitoring (RPM) when measured into a single platform. A support configuration combining a PCM specific platform, some optimizations to an EHR system and well-structured workflow sometimes seem to have heavy administrative and documentation burden can actually become a streamlined and clinical revenue generating service with a unified digital health platform.

Conclusion: Achieve Improved Outcomes with HealthArc’s Principal Care Management Platform

Principal Care Management is not simply an opportunity to bill; it is a care management model for patients facing unclear, impossible hurdles with respect to managing single, complex chronic conditions. PCM helps providers help their patients by engaging in formalized proactive outreach, ongoing monitoring, and modification to the care plan. Ultimately, PCM allows providers to close care gaps, reduce hospitalizations, and improve satisfaction measurements, while generating a reliable source of Medicare reimbursement.

To be successful with PCM, have good intentions are not enough for a provider. They need to focus on effectively executing PCM. It also takes appropriate technology, workflows, and compliance knowledge to scale and meet Medicare’s strict requirements. This is where HealthArc comes in.

HealthArc’s Medicare compliant PCM model includes everything a provider needs in order to start, scale, and optimize their patient programs:

• Automated time-keeping and audit-ready documentation for precise CPT 99424-99427 billing.
• Easy EHR integration to identify eligible patients and manage patient consent.
• Template care plans (customizable, and to the condition) to ensure high quality and targeted patient care.
• Centralized dashboards and secure communications to enable patient management.
• Built-in protocols for integrating Remote Patient Monitoring (RPM) or Chronic Care Management (CCM) when the patient needs.
• Real-time billing readiness and revenue optimization systems to protect against losing reimbursement.
• Ongoing compliance updates and staff training to keep your team audit-ready.

With HealthArc, organizations can transition PCM from a labor-intensive administrative task into a highly profitable, patient-centered care program. It is a turnkey solution that decreases the burden on staff, produces better patient outcomes, and helps to realize the full financial opportunities of Medicare’s care management initiatives.

If your organization plans to increase care for high-risk patients and access new revenue streams, HealthArc’s PCM platform has the technology, know-how and support to do that. Book a demo today to improve care delivery and have a thriving PCM program with HealthArc.

Frequently Asked Questions on Principal Care Management (PCM) in 2026