Principal Care Management

A primary benefit of the PCM codes is that CMS pays for the care management of Medicare patients with a single, high-risk chronic condition, such as cancer. Significantly, specialists managing just one condition, like cancer, can provide PCM services without having to identify a second comorbidity which is required for CCM services. This helps patients by allowing them to receive important care management services such as routine symptom monitoring, medication adherence check-ins, and coordinated care–all important factors to ensure continuity of care and longitudinal care.

The transitioning of care from clinic-provided care to self-care in terms of medication management and follow-up visits can be challenging for patients, especially those with complex chronic conditions. With PCM, clinical staff can support this transition, enabling better-directed self-care, and the clinic can be compensated for this time. The PCM codes enable clinical staff to bill incident-to the billing provider under general supervision, which means that the clinical staff can be located at a centralized location and do not need to be in the same office location as the provider (though the provider must be available to answer questions).

One important factor to note is that PCM compensates providers for activities performed outside of routine in-person (face-to-face) visits with their patients. This includes time spent developing care plans, patient follow-up related to medication management, and discussion of after-visit summaries via the phone. PCM can be billed concurrently with other care management programs, provided that the patient has consented to each of these services. Clinicians can provide PCM services simultaneously with other valuable care management programs such as Transitional Care Management, Remote Physiological Monitoring, and the new Remote Therapeutic Monitoring codes. Fortunately, this care coordination process is familiar to many clinics that have leveraged remote patient monitoring platforms, such as Health Tracker, during the pandemic.

To be eligible for PCM services, patients must meet the following CMS criteria:

• The patient must have one complex chronic condition lasting at least 3 months, which is the focus of the care plan;
• The patient’s condition must be severe enough that the patient was recently hospitalized due to their condition or is at risk for hospitalization. The patient’s condition requires the creation or revision of a disease-specific care plan; and
• The patient’s condition is the type which requires frequent adjustments to the patient’s medication regimen; and/or managing the condition is unusually complex due to associated comorbidities.

A core tenant of Navigating Cancer is to dramatically improve the lives of cancer patients.  We believe PCM is a fundamental tool in achieving this goal. Navigating Cancer is continuously innovating to enable triage and care management functionality in our full suite of integrated, digital oncology solutions. Using Navigating Cancer’s platform, oncology clinics can leverage our PCM-based workflows, which is integrated with our triage system, enabling clinical staff and clinicians to provide meaningful care management services.

Navigating Cancer continues to engage in advocacy with CMS and industry groups to inform future, value-based care models as the payment care model landscape continues to evolve.  Navigating Cancer focuses on providing clinics with insight into optimizing value-based care savings, efficient and quality care management strategies, and other targeted measures to drive quality care and reimbursement for the practices. This is one of many reasons why Navigating Cancer’s solutions continue to be widely adopted as the industry standard in oncology.