As healthcare continues to shift toward value-based, preventive, and patient-centered models, Principal Care Management (PCM) has emerged as a highly focused service designed to improve care for patients with a single serious chronic condition. Unlike Chronic Care Management (CCM), which requires multiple conditions, PCM zeroes in on one qualifying diagnosis—providing structured, reimbursable support for patients who are at risk of complications but not yet eligible for more complex care programs.
Principal Care Management bridges an important care gap: supporting patients with a high-need condition before it escalates or becomes part of a multimorbidity scenario. For healthcare organizations, PCM offers a powerful opportunity to drive better outcomes, optimize workflows, and unlock additional Medicare revenue.
What Is Principal Care Management?
Principal Care Management is a Medicare-reimbursed service designed for patients who have one complex chronic condition expected to last at least three months and that requires specialist-level management, frequent adjustments to care, or puts the patient at significant risk of hospitalization or functional decline.
PCM is defined under CPT codes G2064 and G2065, which cover clinical staff time and provider time, respectively.
This service is ideal for patients who:
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Have one serious condition (e.g., asthma, Parkinson’s, cancer, lupus, Crohn’s, or heart failure)
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Require ongoing monitoring and coordination
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Don’t yet qualify for CCM (which requires two or more conditions)
Key Requirements for PCM Eligibility
To qualify for PCM, a patient must:
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Have one diagnosed chronic condition that is expected to last at least three months
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Have the condition documented in the medical record
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Be at risk of hospitalization or decline in function if not carefully managed
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Require ongoing clinical monitoring, medication adjustment, or treatment coordination
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Provide verbal or written consent to enroll in PCM services
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Be managed by a provider who assumes ongoing responsibility for the care of that condition
Importantly, PCM cannot be billed in the same calendar month as CCM, but it can serve as a precursor to CCM enrollment if the patient develops a second chronic condition.
CPT Codes for Principal Care Management
G2064 – Physician/Non-Physician Practitioner (NPP) Time
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At least 30 minutes per month
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Time must be provided by a physician, PA, or NP
Average reimbursement: ~$91/month
G2065 – Clinical Staff Time
At least 30 minutes per month
Time provided by qualified clinical staff (under general supervision)
Average reimbursement: ~$42/month
Providers may bill both codes if both physician and staff time are met in the same month, potentially generating over $130 per patient, per month.
PCM vs. CCM: What’s the Difference?
Feature
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Number of Conditions
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Focus
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Ideal for
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Billing Codes
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Monthly Time Requirement
CCM
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Two or more
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Whole-person chronic care
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Complex/multimorbid patients
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99490, 99439, G0511 (FQHCs/RHCs)
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20–60+ minutes
PCM
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One
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Specific, complex chronic condition
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Early-stage chronic disease patients
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G2064, G2065
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30 minutes
By design, PCM provides a more targeted care coordination structure and allows practices to engage patients earlier in the disease trajectory—helping to delay progression and reduce unnecessary healthcare utilization.
Benefits of Principal Care Management
1
Improved Patient Outcomes
PCM ensures patients with a serious chronic illness receive focused attention through monthly follow-up calls, medication reviews, coaching, and care coordination. Patients benefit from:
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Early identification of symptom changes
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Adherence monitoring
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Better medication understanding
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Timely referrals and lab follow-ups
This kind of focused care leads to fewer hospitalizations, better medication compliance, and improved patient satisfaction.
2
Support for Under-Managed Populations
Many patients with only one chronic condition fall through the cracks of traditional care coordination models. PCM fills this gap by:
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Engaging patients early in disease progression
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Reducing the time to intervention
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Providing ongoing patient education and lifestyle support
This is especially helpful in underserved or rural communities where patients may lack consistent access to specialists or may struggle with social determinants of health.
3
Increased Practice Revenue
With reimbursements of $42 to $130+ per patient per month, PCM can generate significant additional revenue, especially for practices with large Medicare populations or those operating under shared savings models.
Because PCM uses existing staff and infrastructure, practices can often implement PCM with minimal additional cost, creating a high-ROI care management stream.
4
CMS Compliance and Quality Score Support
Because PCM aligns with value-based care goals, it supports performance metrics like:
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Reduced readmissions
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Medication reconciliation
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Quality documentation
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Patient satisfaction scores (e.g., CAHPS)
It also demonstrates proactive care management during audits and MIPS evaluations.
Typical PCM Activities
Here’s what a monthly PCM interaction might include:
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Review of labs, vitals, or diagnostic tests
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Medication review, reconciliation, or refill coordination
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Discussion of patient-reported symptoms or side effects
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Follow-up after specialist visits or recent changes in care
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Setting or updating self-management goals
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Coaching on symptom control (e.g., diet for CHF)
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Coordination with pharmacies, caregivers, and other providers
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Documentation in the patient’s EHR
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Patient access support (e.g., portals, appointment scheduling)
Like CCM, these activities must be documented and measurable, and time must be logged accurately to support billing.
Implementation Best Practices
1
Identify Eligible Patients
Use your EHR to identify patients with a qualifying chronic condition and no other chronic diagnoses. Focus on those with:
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Poor control of their condition
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Recent hospitalizations
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Multiple medication changes
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Recent referrals to specialists
2
Develop Clinical Workflows
Define who will:
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Track time
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Make monthly calls
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Document in the chart
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Manage billing
Ensure workflows are seamless and compliant with CMS documentation requirements.
3
Train Staff
Train nurses, care coordinators, and MAs on:
- How to conduct PCM interactions
- What questions to ask
- How to record time and document interventions
4
Educate and Enroll Patients
Educate patients about PCM during visits or outreach:
- Explain benefits (e.g., closer support, fewer ER visits)
- Gain verbal or written consent
Document enrollment in the chart
5
Track Outcomes
Monitor:
- Clinical metrics (e.g., A1C, BP, LDL)
- Utilization data (hospitalizations, ED visits)
- Patient engagement rates
These insights help optimize program performance and showcase ROI.
Who Should Offer PCM?
Who Should Offer PCM?
PCM is ideal for:
- Primary care providers managing early-stage chronic illness
- Specialists (e.g., cardiologists, endocrinologists) managing a dominant condition
- FQHCs/RHCs under pressure to improve quality while managing costs
Medicare Shared Savings Program (MSSP) ACOs focused on proactive risk stratification
Conclusion
Principal Care Management is a powerful, underused tool that allows practices to engage patients earlier, prevent disease progression, and generate new Medicare revenue with minimal disruption. With clear eligibility guidelines, strong reimbursement, and measurable impact, PCM is an ideal gateway into chronic care programs—or a standalone solution for patients with a dominant condition.
As practices seek new ways to thrive under value-based care, PCM stands out as a high-value, high-impact program that improves care, increases satisfaction, and supports sustainability.
