Principal Care Management (PCM)

Definition

Principal Care Management (PCM) is a Medicare care management program introduced by the Centers for Medicare & Medicaid Services (CMS) for patients who have a single high-risk chronic condition that dominates their clinical management needs. PCM is CMS’s third care management program alongside Chronic Care Management (CCM, which addresses multiple chronic conditions) and Transitional Care Management (TCM, which covers the 30-day window following a qualifying hospital discharge).

PCM is billed using four CPT codes based on who furnishes the time and how many 30-minute increments are reached in a calendar month: 99424 covers the first 30 minutes of physician or qualified non-physician practitioner time; 99425 covers each additional 30-minute increment of practitioner time; 99426 covers the first 30 minutes of clinical staff time under general supervision; and 99427 covers each additional 30-minute increment of clinical staff time. Medicare reimbursement rates for 2026 vary by locality and are updated annually in the Medicare Physician Fee Schedule.

Regulatory basis

PCM was established by CMS under the Medicare Physician Fee Schedule, finalized in the Calendar Year 2022 Physician Fee Schedule final rule. It is distinct from CCM in a critical way: PCM requires only ONE qualifying chronic condition, not two or more. However, that single condition must place the patient at significant risk of acute exacerbation, hospitalization, or clinical decompensation over the next 3–12 months — a higher individual-condition severity threshold than CCM.

Authoritative billing guidance and annual rate updates are published by CMS at the Medicare Physician Fee Schedule, which covers all care management codes, documentation requirements, and applicable supervision rules for each CPT code.

Who uses it and when it applies

• Patients with a single complex, high-risk chronic condition — examples include newly diagnosed cancer in active treatment, heart failure with a recent decompensation episode, or severe uncontrolled diabetes with complications
• Physicians and qualifying non-physician practitioners (nurse practitioners, physician assistants, clinical nurse specialists, certified nurse midwives) for CPT 99424 and 99425, when they personally furnish the required management time
• Clinical staff under general supervision for CPT 99426 and 99427, which expands the program’s practical reach to care managers and care coordinators working under a supervising practitioner
• Billed once per calendar month per patient when cumulative time thresholds are met within that month — time must be documented to support the claimed code
• Generally mutually exclusive with CCM for the same patient in the same calendar month: PCM focuses on managing one high-risk condition, while CCM addresses patients with two or more chronic conditions; practices should select the appropriate program based on each patient’s clinical profile

Related terms

• Chronic Care Management — the multi-condition analog to PCM, requiring two or more chronic conditions and billed under CPT 99490–99491 and 99439
• Transitional Care Management — the 30-day post-discharge program that addresses patients transitioning from inpatient or other facility settings back to the community
• Remote Patient Monitoring — the device-based monitoring program often layered with PCM to track physiological data for the single qualifying condition between office visits
• Care coordination — the clinical function that PCM operationalizes through structured monthly management activities
• Patient engagement — the engagement layer that supports PCM outcomes by keeping patients connected to their care plan between clinical contacts

How Positive Check relates

Positive Check’s daily wellness calls support PCM programs by providing structured touchpoints focused on the single qualifying condition, generating documentation that clinical staff can review efficiently to meet the 30-minute monthly threshold. Learn more on the chronic care management solutions page.