PCM Software & Services
Principal Care Management Software and Services
HealthArc helps physician practices launch and operate CMS-compliant Principal Care Management programs, handling patient eligibility, care plan documentation, CPT billing (99424–99427) and clinical oversight in one integrated platform.
PCM is built for the patient whose single complex condition drives the care burden: the advanced COPD, heart failure or uncontrolled diabetes patient who never meets the two-condition threshold for CCM.
HIPAA Compliant
AICPA SOC 2 Certified
Pulmonology, cardiology, endocrinology, nephrology & primary care
$60–$100+per enrolled patient / month
PCM CPT codesBillable since Jan 1, 2023
99424Physician / NPP: first 30 minutes~$85–95
99425Physician / NPP: each additional 30 min~$45–55
99426Clinical staff: first 30 minutes~$65–75
99427Clinical staff: each additional 30 min~$45–55
4PCM CPT codes (99424–99427)
1qualifying condition, not two
30 daystypical time to first billable patient
55+EHR systems integrated
Program Overview
What Is Principal Care Management (PCM)?
Principal Care Management (PCM) is a Medicare care management program introduced by the Centers for Medicare & Medicaid Services through the Physician Fee Schedule. PCM is designed for patients who have a single, complex chronic condition expected to last at least three months, which places the patient at significant risk of hospitalization, acute exacerbation, functional decline or death, and which requires the development, monitoring and revision of a disease-specific care plan.
PCM differs from Chronic Care Management (CCM) in scope and focus. Where CCM targets patients with two or more chronic conditions, PCM applies when care complexity is driven by one dominant condition (advanced COPD, heart failure or uncontrolled diabetes, for example) and the patient benefits from a single specialist or primary care physician directing a comprehensive, condition-specific plan.
CMS established four PCM-specific CPT codes (99424, 99425, 99426 and 99427) which became billable on January 1, 2023. They separate physician/NPP-directed service from clinical staff time, and the first 30 minutes from each additional 30-minute increment per calendar month.
HealthArc’s PCM platform gives care teams the infrastructure to enrol eligible patients, generate compliant care plans, document time and submit PCM claims without adding administrative burden to the clinical workflow.
Program type
Medicare Part B care management, billed monthly per enrolled patient
Qualifying patient
One complex chronic condition expected to last 3+ months
Risk standard
Significant risk of hospitalization, acute exacerbation, functional decline or death
Core requirement
A disease-specific care plan that is actively monitored and revised
CPT codes
99424 · 99425 (physician / NPP) and 99426 · 99427 (clinical staff): see the full PCM code reference
Not billable with
CCM or TCM for the same patient in the same calendar month
PCM or CCM? Count the conditions driving the care burden. Two or more → CCM. One dominant condition needing a disease-specific plan → PCM. A patient cannot be enrolled in both during the same calendar month, so HealthArc flags conflicts before enrolment rather than at billing.
Who It’s For
Who Should Offer Principal Care Management?
PCM is designed for physician practices, specialty clinics and health systems that manage patients whose single high-complexity condition requires ongoing coordination and a disease-specific care plan.
Specialties That Bill PCM
- Pulmonology: COPD, asthma, pulmonary fibrosis
- Cardiology: heart failure, hypertension, arrhythmia
- Endocrinology: uncontrolled diabetes, thyroid disease
- Nephrology: chronic kidney disease
- Primary care: complex single-condition cases below the CCM threshold
Practice Types
- Independent specialty and single-specialty clinics
- Multispecialty groups running concurrent PCM and CCM programs
- Health systems and hospital-affiliated outpatient clinics
- ACO-affiliated practices with readmission and utilisation targets
Who Delivers the Service
- Physicians and NPPs billing 99424 / 99425 personally
- Nurses, MAs and care coordinators billing 99426 / 99427 under supervision
- Billing staff and practice administrators managing monthly submission
- Compliance leads maintaining consent and documentation trails
Patient Eligibility Criteria
A patient qualifies for PCM when all of the following are true:
- The patient has a single complex chronic condition expected to last at least 3 months
- The condition places the patient at significant risk of hospitalization, acute exacerbation, functional decline or death
- The condition requires the development or revision of a disease-specific care plan
- The patient has given informed consent
- The patient is not enrolled in CCM, TCM or another conflicting CMS care management service in the same billing period
What this means in practice. A pulmonology clinic with 200 COPD patients who don’t meet the two-condition threshold for CCM can enrol qualifying patients in PCM, generating an estimated $60–$100+ per patient per month while improving care continuity between visits. Run your own panel through the revenue calculator.
The Platform
Principal Care Management Software Built for Clinical Workflows
HealthArc’s PCM software handles every operational layer of a compliant program, from patient identification and consent through care plan documentation, time tracking and CPT code submission.
Patient Enrolment & Eligibility
- Automated identification of eligible single-condition patients from your EHR
- Built-in screening against PCM criteria: condition complexity, risk level, duration
- Digital consent capture with a timestamped audit trail
- Enrolment dashboards showing active, pending and inactive status
Disease-Specific Care Plans
- CMS-compliant templates by condition type: respiratory, cardiovascular, metabolic, renal
- Structured fields for problem list, goals, interventions, medication reconciliation and follow-up
- EHR-linked creation: pull existing problem lists and medication data straight in
- Version history and modification timestamps to support billing documentation
Time Tracking & Documentation
- Clinician and clinical-staff time logging at patient and encounter level
- Automatic monthly aggregation against 99424/99425 and 99426/99427 thresholds
- Documentation templates aligned to CMS requirements for each code tier
- Alerts when a patient nears a monthly time threshold
Concurrent Billing Safeguards
- Simultaneous RPM, CCM and PCM billing where permitted
- Built-in guards against double-counting the same minutes across programs
- Virtual visit integration to log qualifying communication time
- Monthly billing summaries exportable to your PM or billing system
Clinical Decision Support
- Condition-specific alert rules: spirometry thresholds for COPD, weight change for heart failure
- Care gap identification based on care plan adherence and clinical data
- Automated outreach prompts when patients miss touchpoints or breach monitoring thresholds
- Risk stratification so coordinators work the highest-acuity patients first
EHR & Device Integration
- Connects with 55+ EHR systems including Epic, athenahealth, eClinicalWorks and Cerner
- Supports connected devices transmitting via external APIs: BP cuffs, oximeters, scales, spirometers
- Bidirectional sync keeps care plans and clinical notes current in your existing chart
- Structured import where API access is not available
Care Team Model
PCM as a Service: What HealthArc’s Care Team Provides
For practices that want to offer PCM without expanding internal headcount, HealthArc provides a managed service model staffed by licensed clinical professionals who operate as an extension of your practice, under your physicians’ supervision.
Monthly Outreach & Check-Ins
Structured monthly calls with enrolled PCM patients: symptom review, adherence check, and escalation to your clinicians when something changes.
Care Plan Review & Updates
Coordinators review the disease-specific care plan, document revisions and monitor condition progression against goals set by the treating physician.
Medication Adherence & Care Gaps
Adherence verification, refill follow-up and closure of open care gaps, documented against the patient’s monthly record.
Coordination on the Patient’s Behalf
Contact with specialists, pharmacies, home health and community resources, with continuity documentation retained in the platform.
Billing-Ready Documentation
Every minute and activity is logged in HealthArc, ready for physician review and monthly claim submission. No reconstruction at month end.
Physician Oversight Preserved
All clinical staff work under the supervising physician’s direction and within their licensure scope, consistent with CMS supervision requirements for 99426 and 99427.
Option 1
Software only
Your existing care coordinators or nurses run the program in HealthArc. You keep the clinical relationship and the full reimbursement; the platform handles eligibility, care plans, time and billing.
Best for: practices with existing care management staff
Option 2
Managed service
HealthArc’s licensed care team delivers the monthly coordination activities under your physicians’ supervision. Physicians review activity summaries and sign off on care plan changes.
Best for: practices with no spare clinical capacity
Option 3
Hybrid
Your team handles enrolment and high-acuity patients; HealthArc covers routine monthly outreach and documentation volume. Scope moves either direction as your capacity changes.
Best for: practices scaling a program past staff capacity
HealthArc handles scheduling, staffing and quality assurance for the care team. Physicians retain oversight, review monthly activity summaries and approve care plan modifications. The requirements CMS places on the billing practitioner do not transfer to a vendor.
Billing & Reimbursement
PCM CPT Codes 99424, 99425, 99426 and 99427
CMS established four CPT codes for Principal Care Management, billable since January 1, 2023. They are organised by who performs the service (physician/NPP versus clinical staff ) and by time increment per calendar month.
~$85–95
99424
Physician / NPP: First 30 Minutes
- First 30 minutes personally performed by a physician or NPP
- Current disease-specific care plan in place
- Documented patient consent
~$45–55
99425
Physician / NPP: Each Additional 30 Min
- Add-on to 99424 in the same calendar month
- Each further 30-minute increment of physician / NPP time
- Continuous time documentation required
~$65–75
99426
Clinical Staff: First 30 Minutes
- First 30 minutes delivered by clinical staff
- Direct supervision by the billing physician / NPP
- Supervising clinician available, not necessarily present
~$45–55
99427
Clinical Staff: Each Additional 30 Min
- Add-on to 99426 in the same calendar month
- Each further 30-minute increment of clinical staff time
- All activity and time logged in a compliant platform
Documentation Requirements for Every PCM Claim
- A single qualifying complex chronic condition meeting PCM eligibility criteria
- Documented informed patient consent before services begin
- A current, disease-specific care plan that is monitored and revised
- Monthly time logs meeting the threshold for the code billed
- Evidence of the coordination performed: calls, referrals, medication work
- No concurrent CCM or TCM claim for the same patient that month
The Monthly Billing Workflow in HealthArc
1
HealthArc auto-identifies patients who met the monthly time threshold from logged activity
2
The platform generates a billing summary with CPT recommendations, documented time and care plan status
3
The supervising physician reviews and approves the billing batch
4
Codes are exported or transmitted to your practice management or billing system
5
A full audit trail of time and activity is retained per patient, per month
A 200-patient PCM panel billed at the 99426 clinical-staff rate is an estimated $13,000–$15,000 per month before any additional 30-minute increments.
Calculate Your RevenueReimbursement figures are approximate national non-facility Medicare averages and vary by geographic locality, facility status, payer and calendar year. CMS updates them annually in the Physician Fee Schedule, so don’t treat the numbers here as a quote. Verify current rates at cms.gov or with your MAC before you bill.
Implementation
How to Start a Principal Care Management Program
HealthArc’s implementation gets a PCM program operational within about 30 days without disrupting existing workflows.
1
Days 1–7
Practice Setup & EHR Integration
HealthArc’s integration team connects the platform to your EHR. Bidirectional sync is established for demographics, problem lists, medications and care notes, and your staff receive role-based access and a guided walkthrough.
2
Days 7–14
Patient Identification & Enrolment
An eligibility scan runs against your panel to find candidates who meet PCM criteria: one complex condition, appropriate risk level, no conflicting CMS enrolment. Your care team confirms eligibility and starts the consent workflow.
3
Days 14–21
Care Plan Creation
A disease-specific care plan is built for each enrolled patient from HealthArc’s condition-specific templates, pre-populated with EHR clinical data. Physicians review and approve each plan before services begin.
4
Days 21–30+
First Month of Active Monitoring
Coordinators (yours or HealthArc’s) begin monthly outreach and monitoring. Time is logged in-platform, and at month end HealthArc produces billing-ready CPT summaries for physician review.
5
Ongoing
Program Reviews & Optimisation
Dedicated implementation support, quarterly program reviews and access to clinical operations specialists who help lift enrolment rates, documentation compliance and monthly reimbursement capture.
Interoperability
EHR Integration for Principal Care Management
HealthArc integrates with 55+ EHR and practice management systems, so your PCM program runs as a connected layer on top of existing clinical infrastructure, not as a separate silo your team has to re-key data into.
- Bidirectional sync of demographics, problem lists, medication lists, allergies and care notes
- Automated import of chronic condition diagnoses to drive PCM eligibility screening
- Care plan data written back to the patient’s EHR record after physician approval
- Encounter notes and activity logs syncable to the chart for continuity of care
Bidirectional Sync
Diagnoses and medications in; care plans and documentation back out.
FHIR R4 & HL7
Standards-based connection wherever your vendor exposes an endpoint.
Connected Devices
BP cuffs, oximeters, scales, spirometers and glucometers feed the PCM monitoring record and trigger condition-specific alerts.
No IT Build
Configuration is HealthArc’s work, not a project for your IT team.
Commonly Integrated Systems
Epic
athenahealth
eClinicalWorks
Cerner (Oracle Health)
Allscripts / Veradigm
NextGen Healthcare
Greenway Health
DrChrono
AdvancedMD
HL7 FHIR R4 & API
If your EHR isn’t listed, HealthArc’s integration team will confirm connectivity during discovery. Most systems with a supported API or CCD export can be connected.
Reporting & Analytics
PCM Reporting and Program Analytics
Running a compliant, revenue-generating PCM program requires visibility into enrolment, documentation completeness, time thresholds and billing performance.
Enrolment Dashboard
- Total enrolled patients and enrolment trend over time
- Eligible-but-not-enrolled patients, ranked by opportunity
- Dropout rate and reasons
Monthly Billing Readiness
- Patients who have reached CPT thresholds versus those who have not
- Time gaps identified while the month is still open
- Projected versus captured reimbursement by code
Care Plan Compliance
- Patients with current versus overdue care plan reviews
- Flagged by condition and risk level
- Version history for every plan revision
Revenue Capture
- Estimated versus actual monthly PCM reimbursement
- Broken down by CPT code and by provider
- Trend over the life of the program
Patient Engagement
- Outreach attempts and completed contacts per patient
- Non-responder flags for escalation
- Contact method effectiveness
Audit-Ready Documentation Log
- Timestamped record of all PCM activity per patient, per month
- Exportable for compliance review or payer audit
- Staff attribution on every entry
Every report is available in the HealthArc dashboard and can be scheduled for automated delivery to administrators and practice managers.
Compliance & Security
HIPAA Compliance and Data Security
HealthArc is built to meet the compliance and security requirements of healthcare organisations operating federally regulated care management programs.
Compliance Capabilities
- HIPAA-compliant architecture with a BAA available for every customer
- Role-based access: staff see only patients on their care team
- Audit logs for data access, care plan changes and billing actions
- CMS-compliant documentation workflows for PCM billing requirements
Data Security
- Encrypted in transit (TLS 1.2+) and at rest (AES-256)
- Hosted on SOC 2-compliant cloud infrastructure
- Regular third-party security assessment and vulnerability scanning
- No PHI on end-user devices: browser access with session controls
Regulatory Alignment
- Workflows designed against CMS guidance for PCM in the Physician Fee Schedule
- Platform updated when CMS changes PCM codes or documentation requirements
- Eligible provider categories and supervision rules enforced in-product
- Concurrent-program conflicts blocked before enrolment
Results
What a PCM Program Looks Like in Practice
The numbers below are the mechanics of the program: CMS rates, published prevalence data and the arithmetic that follows from them. Ask our team for a revenue projection built on your own panel size and specialty.
~30 daysFrom kickoff to first billing-eligible PCM patients
$60–$100+Estimated monthly reimbursement per enrolled patient
76%of U.S. adults 65+ live with at least one chronic condition (CDC)
7 in 10U.S. deaths annually are attributable to chronic disease (CDC)
Do the panel maths before you commit. Tell us your specialty and how many patients carry one dominant complex condition, and we will model the billable population, the code mix and the monthly reimbursement range. Calculate PCM revenue.
HealthArc supports more than 100,000 patients across remote monitoring and care management programs. Practice-specific outcome data is shared under NDA during evaluation rather than published here.
FAQ
Frequently Asked Questions About Principal Care Management
The questions practices ask most when evaluating PCM programs and software vendors.
What is principal care management (PCM)?
Principal Care Management (PCM) is a Medicare care management program created by CMS for patients with a single complex chronic condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation, functional decline or death. PCM requires a disease-specific care plan and ongoing monthly care coordination performed by a physician, NPP or supervised clinical staff.
CMS introduced PCM CPT codes 99424, 99425, 99426 and 99427, which became billable on January 1, 2023.
What is the difference between PCM and CCM (chronic care management)?
The primary difference is the number of qualifying conditions. Chronic Care Management requires a patient to have two or more chronic conditions. Principal Care Management applies when a patient has one single complex chronic condition that drives their care complexity.
PCM also centres on a disease-specific care plan rather than a general chronic condition plan. A patient cannot be enrolled in both PCM and CCM in the same calendar month. Learn more about Chronic Care Management.
What are the CPT codes for principal care management and what do they pay?
CMS uses four CPT codes for PCM billing:
- 99424: physician / NPP, first 30 minutes per month, approximately $85–$95
- 99425: physician / NPP, each additional 30 minutes, approximately $45–$55
- 99426: clinical staff under physician supervision, first 30 minutes, approximately $65–$75
- 99427: clinical staff, each additional 30 minutes, approximately $45–$55
Rates are national non-facility Medicare averages and vary by geographic locality and facility type. Verify current-year rates at cms.gov. See the full PCM CPT code reference.
Who can bill for principal care management services?
PCM can be billed by physicians and non-physician practitioners (including nurse practitioners, physician assistants and clinical nurse specialists) who are eligible to bill Medicare under the Physician Fee Schedule.
Clinical staff such as nurses, medical assistants and care coordinators can deliver PCM services under codes 99426 and 99427, but only under the supervision of a billing physician or NPP. PCM is not billed by hospitals or facility-based outpatient departments at facility rates.
What are the patient eligibility requirements for PCM enrolment?
A patient is eligible for PCM if they (1) have a single complex chronic condition expected to last at least 3 months, (2) the condition places them at significant risk of hospitalization, acute exacerbation, functional decline or death, (3) the condition requires the creation, monitoring or revision of a disease-specific care plan, and (4) the patient provides informed consent and is not concurrently enrolled in CCM, TCM or another conflicting CMS care management program during the same billing period.
How does PCM software reduce administrative burden for care teams?
PCM software automates the manual components of running a compliant program: identifying eligible patients from the EHR, generating condition-specific care plan templates, logging staff time against monthly thresholds and producing billing-ready CPT summaries.
Without dedicated software, care teams track time by hand, maintain separate care plan documents and reconcile billing data each month. That is error-prone work, and it produces exactly the documentation gaps that get claims denied.
How long does it take to launch a PCM program with HealthArc?
Most practices go from signed agreement to first billing-eligible patients within about 30 days. The timeline covers EHR integration (days 1–7), eligibility screening and consent (days 7–14), care plan creation (days 14–21) and the first active monitoring month (days 21–30+). It varies with EHR complexity and the size of the initial cohort.
Get Started
Start a Principal Care Management Program at Your Practice
HealthArc’s PCM platform and managed service model give you everything needed to enrol eligible patients, maintain compliant care plans, document clinical staff time and submit PCM claims without expanding your internal headcount.
- How HealthArc finds single-condition PCM candidates in your panel
- The disease-specific care plan and monthly outreach workflow
- How physician and clinical-staff time map to 99424–99427
- What a completed billing batch looks like before submission
- A revenue projection for your patient panel and specialty
Schedule a Demo
Calculate PCM Revenue
HIPAA Compliant • SOC 2 Certified • No long-term contracts
sales@healtharc.io • +1-201-885-5571
sales@healtharc.io • +1-201-885-5571
How can HealthArc help you?
Interested in a demo or just general questions? Fill out the form below and a representative will respond shortly!
Resources
Latest on Principal Care Management
Practical guidance on PCM eligibility, 99424–99427 billing and single-condition care coordination.
May 13, 2026
HealthArc vs Cadence: User Experience Compared
Compare HealthArc vs Cadence user experience, usability, navigation, and workflow efficiency for remote patient monitoring and chronic care management teams.
Read articleOctober 18, 2025
Principal Care Management (PCM): A High-Impact Strategy for Specialists under Value-Based Care
PCM meaning in healthcare: what Principal Care Management is, who qualifies, how it differs from CCM, CPT codes 99424–99427, and Medicare billing basics.
Read articleAugust 19, 2025
Principal Care Management (PCM) 2026: CPT Codes, Workflows & Medicare Updates
How to bill Principal Care Management: CPT codes 99424–99427, time and documentation rules, the PCM workflow, and 2026 Medicare reimbursement.
Read article