Medicare’s New 2020 Chronic Care Service: Principal Care Management

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Medicare chronic care service
by Amanda Martin

CMS recently finalized its Medicare coverage changes for 2020 and we’ve found a little something to be excited about. Officially dubbed Principal Care Management (PCM), this new program will allow medical providers to bill Medicare for providing care management services to beneficiaries who have only one high-risk qualifying condition or diagnosis.

If your practice is already providing Medicare beneficiaries with Chronic Care Management (CCM), this new program should be fairly easy to implement and incorporate into your existing care management program. Because PCM eligible patients only need to have a single serious chronic condition to qualify, the reach of this new program will be significant and open-up care opportunities for more patients while increasing revenue-generating opportunities for your practice. 

Principal Care Management in a Nutshell

Medicare released two new HCPCS codes that can now be used to bill for PCM services:

  • G2064: For at least 30 minutes of provider/physician time per calendar month. This code may be used by a physician, nurse practitioner, or physician assistant. ($92.03 Average Reimbursement)
  • G2065: For at least 30 minutes of clinical staff time billed once per calendar month. ($39.70 Average Reimbursement)

Additionally, to bill for PCM services the following requirements must be met:

  • The patient must have one qualifying chronic condition expected to last between three to 12 months or until death.
  • The condition has resulted in hospitalization and/or puts the patient at an increased risk of hospitalization, or the condition significantly increases the risk of functional decline or death.

PCM services may not be billed with other care management codes such as CCM (CPT’s 99490, 99491, 99487, 99489) for the same patient in the same month. Also notable, CMS has not placed any restrictions on who may perform PCM services meaning specialty providers are also eligible to participate.

The Takeaway On Principal Care Management

Medicare is quickly recognizing the value in effectively managing their beneficiary’s chronic health conditions and is incentivizing providers in hopes that they will find cost-effective ways to provide care management services. While PCM and CCM are similar in design, PCM differs because patients only need to have one qualifying chronic condition instead of two. PCM also differs from CCM in how the patient’s care plan is developed.

When creating the care plan for a patient enrolled in PCM, the focus must be on the specific disease or chronic condition whereas the care plan for CCM is much broader in scope. When documenting PCM services, the billing provider also needs to be mindful that they are responsible for documenting all the patient’s care for the condition being managed, including any care received from outside providers.   

PCM will be a game-changer for reaching patients with a single chronic condition making it easier for you to manage their care and receive the compensation you deserve. You can now receive reimbursements for the time you spend on complicated cases where medications and care plans change frequently, providing a focus on managing the condition before it increases the patient’s risk for hospitalization. 

If you’re not sure how to implement this exciting new revenue-generating opportunity into your existing care management program, Prevounce can help.  Our intelligent programs incorporate the tools you need to build your care management program to Medicare specifications, ultimately resulting in healthier patients and increased reimbursements for your practice.  

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