Principal Care Management (PCM): A High-Impact Strategy for Specialists under Value-Based Care

Value-based care models are reshaping how healthcare providers deliver services, emphasizing improved patient outcomes and cost efficiency over volume of procedures. In this landscape, specialists are increasingly looking for ways to actively manage chronic conditions between visits. Principal Care Management (PCM) has emerged as a powerful strategy for physician specialists to provide proactive, coordinated care for high-risk patients while aligning with value-based care goals [1]. This on-page guide explains what PCM is, how it differs from traditional Chronic Care Management (CCM), and why it offers significant benefits for specialists and their patients under value-based care.

What is Principal Care Management (PCM)?

Principal Care Management is a Medicare-covered care management service focused on one serious, high-risk chronic condition for a patient. Unlike CCM (which requires two or more chronic conditions), Principal Care Management (PCM) is designed for patients whose health risks are primarily driven by a single condition and who require ongoing, structured management. According to the Centers for Medicare & Medicaid Services (CMS), PCM services focus on a single, complex chronic condition expected to last at least 3 months and that places the patient at significant risk of hospitalization, acute aggravation or decompensation, functional decline, or death[2]. In other words, PCM targets the patients’ primary health challenge—for example, advanced heart failure, severe COPD, uncontrolled diabetes, or any one condition that could severely impact the patient if not actively managed.

Why did Medicare introduce PCM? Prior to PCM’s introduction, Medicare’s care management reimbursement (CCM) required multiple chronic conditions, which left a gap for patients with one predominant condition. CMS heard from stakeholders (particularly specialist physicians) that managing a single complex disease can demand significant time and resources not accounted for by existing billing codes. [3]. To address this gap, Medicare created new PCM billing codes in 2020, recognizing that some single conditions “cannot be managed as effectively in the primary care setting and instead require management by a more specialized practitioner” [4]. In fact, CMS anticipated that specialists—such as cardiologists, pulmonologists, endocrinologists, etc.—would be the primary users of PCM services, given their focus on specific complex conditions. [4].

Principle Care Management (PCM) vs. Chronic Care Management (CCM): Key Differences

Both PCM and CCM are monthly care coordination services, but they serve different patient needs and provider roles:

• Number of Conditions: CCM is intended for patients with two or more chronic conditions, whereas PCM is for patients with one complex chronic condition that is high-risk [3][4]. Many Medicare beneficiaries have one dominant condition that drives their healthcare needs; PCM was designed to support those patients without the requirement of multiple conditions.
• Typical Provider: CCM is usually handled by primary care providers, managing care across multiple chronic conditions. PCM, on the other hand, is typically led by a specialist physician focusing on the patient’s principal condition. CMS explicitly noted that a single complex condition might be better managed by a specialist, with the primary care practitioner still overseeing overall patient care [5]. For example, a primary care doctor may remain the general coordinator for a patient, but a cardiologist could provide PCM services for that patient’s advanced heart failure—developing a disease-specific care plan, making frequent medication adjustments, and closely monitoring symptoms [5]. The goal is often to stabilize the condition through specialist-led management so that overall care can eventually be handed back fully to primary care [5].
• Concurrent Services: Medicare does not allow the same provider to bill PCM and other care management (like CCM) for the same patient in the same month [6]. However, it is important to note that different providers can coordinate a patient’s care by using separate programs. For instance, a primary care provider could bill CCM for the patient’s multiple issues while a specialist bills PCM for the one complex condition—as long as they are managing different aspects of care [5][7]. In fact, CMS acknowledges that patients often have more than one complex condition and could receive PCM services from more than one specialist simultaneously, each addressing a different condition, if needed [8]. This team-based approach guarantees that the same clinician provides focused attention to each condition without any overlap.
• Billing Codes & Time Requirements: Both programs use time-based monthly billing. PCM services require at least 30 minutes of care management per calendar month devoted to the single condition [9]. Medicare has designated four CPT codes for PCM (99424, 99425, 99426, 99427) to report these services. The first 30 minutes of Principal Care Management (PCM) in a given month is billed using the base CPT code, and if more time is spent, an add-on code covers each additional 30-minute increment. The codes also distinguish who provides the service: one set (99424, 99425) is used when the physician or qualified health professional personally provides the care management, and the other set (99426, 99427) is used for time spent by clinical staff under the physician’s supervision, often as “incident to” services. By contrast, CCM has its own codes (such as 99490, 99439, 99491, etc.) with slightly different time thresholds and requirements (CCM typically starts at 20 minutes for non-complex CCM). Both PCM and CCM require documentation of the time and activities, but PCM’s singular focus can streamline the care plan around one condition.
• Patient Eligibility and Consent: Both PCM and CCM require that the patient be informed and express consent for the service, with an initiating visit (an office visit, annual wellness visit, or similar) if the patient is new or hasn’t been seen in the past year [11][12]. The initiating visit ensures there is a comprehensive evaluation and a care plan start. After the initial setup, services are typically provided on an ongoing monthly basis through non-face-to-face interactions, such as phone calls, care coordination, and medication management. Only one practitioner per month may bill CCM for a patient, whereas PCM’s structure allows multiple practitioners per month for different conditions, as noted [13].

Why PCM Is a High-Impact Strategy for Specialists

For physician specialists, PCM represents a significant opportunity to improve patient care and succeed under value-based care arrangements. Here’s why PCM is so impactful for specialists:

• Focus on the Most Critical Condition: Specialists often deal with patients whose primary health issue falls squarely in their domain (for example, a rheumatologist managing advanced rheumatoid arthritis or a nephrologist managing late-stage kidney disease). PCM enables the specialist to focus their care on a single condition, thereby preventing any gaps in care between infrequent office visits. The specialist can create a detailed, disease-specific care plan and provide regular check-ins, even when the patient is not in the clinic.
• Compensation for Care Coordination: Traditionally, much of the phone calls, patient education, medication adjustments, and coordination with other providers that specialists do between appointments were uncompensated under fee-for-service payment. PCM addresses this issue by reimbursing specialists for the monthly care management work related to the targeted condition. For example, a pulmonologist who spends time each month adjusting a severe COPD patient’s inhaler regimen, arranging oxygen equipment, and following up on symptoms can bill Medicare for that time through PCM codes (assuming at least 30 minutes of cumulative effort) [9]. This type of system provides additional revenue and incentivizes the specialist to be more initiative-taking with patient outreach and support.
• Improved Patient Outcomes: Initiative-taking management of chronic diseases by specialists can lead to better outcomes, which is precisely what the value-based care model rewards. With PCM, specialists regularly engage patients to prevent complications and hospitalizations. Early evidence and expert observations have noted that PCM services can reduce hospital readmissions for high-risk patients by catching warning signs early and managing them outpatient [14]. For instance, a cardiologist calling a patient with heart failure each week might adjust diuretics to avert fluid buildup that could have led to an ER visit. Similarly, PCM tends to improve medication adherence through frequent follow-ups and patient education [14]. Patients are less likely to fall off their treatment plan when a care manager or specialist is checking in regularly. This sustained engagement also enhances patient satisfaction and confidence, as they feel their specialist is integrally involved in their care.
• Alignment with Value-Based Metrics: By managing the patient’s main health issue more effectively, specialists help reduce overall costs and improve quality measures, which are important goals in value-based care contracts (like accountable care organizations or bundled payment programs). Value-based performance evaluations thoughtfully reflect fewer emergency visits and hospital stays, improved disease-specific measures (e.g., blood glucose control in diabetes or fewer asthma exacerbations), and higher patient-reported outcomes. PCM gives specialists a structured way to impact these measures. It extends care beyond the clinic visit, which is crucial for chronic disease management success.
• Collaboration with Primary Care: PCM fosters a team-based care approach where specialists and primary care physicians collaborate rather than work in silos. The primary care provider remains the coordinator for the patient’s overall health needs, while the specialist intensely manages the key condition. CMS specifically described scenarios where a primary care practitioner oversees general care and the specialist provides PCM for the complex condition, with ongoing communication between them. This collaboration ensures the patient receives comprehensive care: the specialist prevents the condition from spiraling out of control, and the primary care doctor addresses the rest of the patient’s health issues. Such coordination is integral to value-based care’s emphasis on holistic, patient-centered management.
• Ability to Handle Multiple Complex Conditions: Many patients, especially seniors, juggle several chronic conditions. PCM’s flexibility allows more than one specialist to be involved when appropriate—for example, an oncologist managing cancer and a cardiologist managing heart failure for the same patient in parallel. Medicare permitting different clinicians to bill PCM in the same month for different conditions acknowledges the reality of multi-morbidity. Specialists can focus on their area, while other providers manage different conditions, giving the patient coordinated, expert care. This distributed approach can dramatically improve care for complex patients and is in line with coordinated, multidisciplinary care models encouraged under value-based care.

Implementing PCM in Practice: What Specialists Should Know

Launching a PCM program as a specialist practice involves meeting certain requirements and adopting new workflows. Below are key components to successfully implement PCM:

1. Patient Eligibility: Identify Medicare patients (Part B) who have one severe chronic condition that is the main source of their health complications. According to CMS guidelines, a qualifying condition is expected to last at least 3 months (often much longer) and carries a significant risk of death, acute flare-ups, or functional decline if not well managed [15]. Typically, these are patients with conditions like advanced cardiac disease, uncontrolled endocrine disorders, progressive neurological conditions, etc., where focused monitoring and management could prevent crises.
2. Initiating Visit & Consent: Make sure an initiating visit has been completed (if required) and that the patient has provided informed consent for PCM services. [12]. The initiating visit can be an evaluation & management office visit, an annual wellness visit, or another comprehensive visit where the condition and care plan are reviewed. During this visit (or for established patients, during a recent visit), explain the PCM program to the patient: that you or your team will be contacting them regularly, that there may be a small co-pay (Medicare coinsurance) for the service, and that they have the right to opt out anytime. Document consent in the medical record.
3. Care Plan Development: Create a personalized care plan for the patient’s principal condition. This plan should outline the patient’s health goals, the specialist’s prescribed interventions (medications, therapies, and diet/lifestyle guidance), warning signs to monitor, and any needed home services or equipment. The care plan should be readily available to the care team and shared with the primary care provider and patient/caregiver [16]. In PCM, because the focus is narrow, the care plan drills deep into managing that one illness (for example, a care plan for heart failure would include daily weight monitoring, dietary sodium limits, medication titration protocols, etc.).
4. Monthly Care Management Activities: Plan for how your practice will deliver at least 30 minutes of care management per month for the PCM patient. The specialist physician can personally conduct these activities, or they can assign them to clinical staff (nurses, care coordinators, and pharmacists) under general supervision. Common PCM activities include:
   1. The specialist physician may conduct regular check-in calls, such as weekly or biweekly, to assess symptoms, adherence, and the need for appointments.
   2. Medication management, such as adjusting dosages, managing side effects, and reconciling medications after any hospital visit.
   3. Coordinating referrals or tests related to the condition, such as scheduling a necessary imaging study or consulting another sub-specialist, is crucial.
   4. Patient education and coaching on managing the condition (dietary advice, warning signs, device usage like inhalers or blood glucose monitors).
   5. Arranging community or social support if needed (e.g., connecting a patient with heart failure to a nutritionist or a heart failure disease management class).
   6. All patient contacts and care management activities are documented with the date, time spent, and a brief description. This will ensure the PCM base code is billable once the first 30 minutes are met. If the total time exceeds the base 30 minutes, use the add-on code to capture each additional 30-minute increment of care provided.
5. Billing and Coding: Use the correct CPT codes for PCM on your Medicare claims. As noted, CPT 99424 covers the first 30 minutes of physician- or NPP-provided PCM services in a month, while 99425 is an add-on for each additional 30 minutes. CPT 99426 applies to the first 30 minutes of clinical staff time (directed by the physician) per month, and 99427 covers each additional 30 minutes of staff time. Only one practitioner—whether a physician, NPP, or supervised clinical staff—may bill PCM for a given patient and condition in the same month. To remain compliant, avoid overlapping care management claims: if you are billing PCM for a patient’s condition, you should not bill Chronic Care Management (CCM) or any other care management code for that same patient during that month. When multiple specialists are involved, coordinate responsibilities so each provider manages and bills for distinct conditions. Medicare may reject claims in cases of duplication—for instance, when two providers bill PCM for the same condition or when PCM overlaps with CCM for the same patient in a single month. Proper documentation and communication between providers help ensure accurate claim submission and prevent reimbursement conflicts.
6. Collaboration and Communication: Since PCM often involves a specialist working alongside a primary care physician, maintain open lines of communication. Share the care plan and monthly updates with the primary care provider (and any other involved providers) so everyone stays informed. This improves patient care and helps demonstrate the value of PCM to the overall care team. Clear documentation in the EHR, as well as occasional case conferences for complex patients, can be useful.
7. Compliance and Quality Monitoring: As with any Medicare service, ensure compliance with all documentation requirements. Monitor the condition-specific quality metrics, such as the patient’s HbA1c trends or adherence to foot exams, if you are managing diabetes under PCM. The aim is to see measurable improvements or stabilization. This will help in both justifying the service (during any audits) and in proving the value of PCM in value-based payment models.

Benefits of PCM for Patients and Specialists in Value-Based Care

PCM creates a win-win scenario under value-based care by benefiting both patients and healthcare providers (including specialists). Here are some key benefits:

• Better Chronic Disease Control: Patients receive more frequent touch points and support for their condition. This continuous oversight helps catch problems early. For example, timely medication tweaks or interventions in a PCM program can prevent a minor issue from turning into an acute emergency. As noted earlier, PCM has been effective at reducing hospital readmissions for patients with high-risk conditions by managing issues proactively after hospital discharge. Avoiding even one hospitalization not only spares the patient from health risks and stress but also saves significant healthcare costs—a primary aim of value-based care.
• Higher Patient Engagement and Satisfaction: With PCM, patients have a resolute care team member or specialist reaching out regularly. This level of attention makes patients feel supported in managing their illness. It also empowers them through education and consistent follow-up. Patients are more likely to adhere to their treatment plans when they know someone is checking in. In value-based care surveys, patient satisfaction and engagement are important metrics—and PCM can boost both by giving patients personalized care. Regular follow-ups under PCM keep patients engaged in their health, improving their confidence in self-management and in the healthcare system’s responsiveness [17].
• Care Coordination and Communication: PCM formalizes the coordination that is critical for complex conditions. The specialist often serves as a navigator for that condition—coordinating with primary care, pharmacists, home health, or other services. For instance, a specialist managing a patient’s uncontrolled diabetes under PCM might coordinate with an ophthalmologist for annual eye exams and a dietitian for nutritional counseling, ensuring a 360-degree approach. This level of care coordination is what value-based care encourages: breaking down silos between providers. It results in a more cohesive care experience for the patient and reduces the likelihood of conflicting treatments or oversights.
• Specialist Practice Performance: From the specialist’s perspective, PCM can improve practice performance indicators. Under alternative payment models (like Accountable Care Organizations or specialty-focused bundles), specialists who keep their patients healthier and out of the hospital contribute to shared savings and may receive performance bonuses. Even within traditional Medicare fee-for-service, the reimbursement from PCM codes provides a new revenue stream that rewards time spent on care quality, not just procedures. As of 2025, the Medicare national average reimbursement for PCM is on the order of tens of dollars per patient per month (e.g., roughly $84 for a physician-directed month of PCM, based on initial CMS estimates) [18]. While not enormous per patient, these amounts can add up and also offset costs if the practice hires clinical staff to assist with care management. Moreover, by documenting and billing PCM, a specialist practice is effectively demonstrating the value of the work they do between visits—which can be important in negotiations with payers and in public reporting.
• Preparation for Advanced Care Models: Engaging in PCM prepares specialists for more advanced value-based initiatives. For example, Medicare is increasingly moving toward bundled payments or population health programs that expect providers to manage care beyond episodic visits. By implementing PCM, specialists build the workflows (like 24/7 access, care plans, and data tracking) that could later be useful for participating in models like Advanced Primary Care Management (APCM) bundles or specialty-specific alternative payment models. In fact, PCM is one component of Medicare’s new APCM bundle for primary care starting in 2025 [19], indicating that such care management activities are central to the future of care delivery. Specialists who master PCM will be at the forefront of delivering coordinated, continuous care.

Frequently Asked Questions (FAQs)

Conclusion

Principal Care Management is proving to be a high-impact strategy for specialists navigating the shift to value-based care. By concentrating on a patient’s most pressing chronic condition, specialists can deliver targeted, initiative-taking care that keeps patients healthier and reduces avoidable healthcare utilization. Medicare created PCM to acknowledge that specialists play a key role in managing complex conditions and should be supported and reimbursed for their care beyond the occasional office visit. Under value-based care, healthcare providers’ success is measured not only by what they do in the clinic but also by how well their patients’ health outcomes improve over time. PCM enables specialist physicians to take accountability for outcomes in their area of expertise, offering regular care coordination, patient education, and clinical intervention that drive those outcomes. The result is better-controlled chronic conditions, more empowered patients, and a healthcare system that rewards quality. Specialists who embrace PCM are not only unlocking new revenue and improving patient satisfaction today but also positioning themselves as leaders in the collaborative, outcome-focused healthcare model of tomorrow.

In summary, Principal Care Management gives specialists a structured pathway to extend care beyond the consult room—aligning perfectly with value-based care’s mantra of “the right care at the right time.” By using PCM programs, specialist practices can both improve patient health and succeed with value-based payment systems, making it a highly effective approach in today’s healthcare.

Visit HealthArc.io to learn how Healtharc can help your organization implement PCM efficiently and in full compliance with CMS documentation standards.

Sources: 

• Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network – Chronic Care Management Services (Jun 2025)
• CMS, CY 2020 Physician Fee Schedule Final Rule (as summarized by ASRA Pain Medicine)
• Sudeep Bath, HealthArc – Principal Care Management (PCM) 2026: CPT Codes, Workflows, & Medicare Updates
• ASHP, Chronic Care Management FAQ (Oct 2024)