Broad primary care vs. one high-risk condition
Principal Care Management (PCM) pays for managing a single high-risk chronic condition, and it is often billed by specialists. Advanced Primary Care Management (APCM) pays for the whole primary-care relationship each month. They can look alike on paper, but they are built for different practitioners.
| Question | APCM | PCM |
|---|---|---|
| Codes | G0556, G0557, G0558 | 99424, 99425 (practitioner) · 99426, 99427 (clinical staff) |
| Patient scope | The patient’s overall primary care, tiered by complexity | One complex chronic condition expected to last at least three months |
| Time tracking | No monthly minute threshold | 30-minute increments of documented time |
| Typical biller | The practitioner responsible for primary care | Often a specialist managing the condition |
| Care plan | Patient-centered, comprehensive | Disease-specific |
What PCM covers
PCM is meant for a patient whose single condition is serious enough to need focused management. The condition may have led to a recent hospitalization, puts the patient at significant risk of decline, or requires frequent treatment changes. The billing practitioner builds and monitors a disease-specific care plan.
Like CCM, PCM is on the list of care-management services CMS considers duplicative of APCM when the same practitioner reports them for the same patient in the same month. A specialist billing PCM and a primary care practice billing APCM is a different situation. Check current CMS and payer guidance for each case.
How a primary care practice should think about it
- If you are the patient’s primary care home, start with APCM
- Use PCM when a patient’s care centers on one condition you manage and APCM does not fit
- Coordinate with specialists who may already bill PCM for the same patient
- Do not report both codes yourself for the same patient and month
- Compare with APCM vs. CCM if the patient has two or more conditions