What Conditions Qualify for PCM?

PCM is designed for patients with:

• One chronic condition expected to last at least three months.
• A recent hospitalization or acute risk of hospitalization, functional decline, exacerbation, or death.
• Conditions considered complex and requiring frequent management adjustments.

Common PCM conditions include:

• Diabetes with complications
• Congestive heart failure (CHF)
• Chronic obstructive pulmonary disease (COPD)
• Advanced chronic kidney disease (CKD)
• Severe hypertension
• Complex autoimmune diseases

PCM Reimbursement: CPT Codes Explained

PCM reimbursement involves specific CPT codes for provider and clinical staff activities:

Provider Management Codes:

• 99424
  
  • Initial 30 minutes per month by a physician or qualified healthcare professional (QHP).
  • Activities: Creating and adjusting care plans, managing complex medication regimens, patient communication, and care coordination.
  • Typical Reimbursement: $80–$90/month per patient.
• 99425 (Add-on)
  
  • Additional 30 minutes by physician/QHP.
  • Always billed with 99424.
  • Typical Reimbursement: $60–$70 per additional 30 minutes.

Clinical Staff Management Codes (Under Provider Supervision):

• 99426
  
  • Initial 30 minutes per month by clinical staff (e.g., nurses, medical assistants).
  • Activities: Patient check-ins, medication adherence, symptom monitoring, education, care coordination.
  • Typical Reimbursement: $60–$70/month per patient.
• 99427 (Add-on)
  
  • Additional 30 minutes by clinical staff.
  • Always billed with 99426.
  • Typical Reimbursement: $50–$60 per additional 30 minutes.

Common PCM CPT Code Questions:

• Can PCM codes be billed alongside CCM or RPM?
  
  • Yes, as long as each service is separately fulfilled and documented.
• Is time documentation necessary?
  
  • Yes, meticulous documentation of time spent and activities is crucial.
• Is patient consent required?
  
  • Yes, documented patient consent (verbal or written) is mandatory.

How CCN Health Simplifies PCM Implementation:

CCN Health streamlines PCM by offering integrated solutions for documentation, care coordination, and billing support.

Key CCN Health Features:

• Automated Time Tracking
  
  • Logs clinical and administrative time for accurate billing.
• Multi-Access Collaboration
  
  • Simultaneous access to patient records ensures real-time care coordination.
• Clinical Surveys
  
  • Conduct structured clinical assessments and patient check-ins.
• Customizable Care Plan Templates
  
  • Quickly set and track patient-specific goals, medications, symptoms, interventions, and schedules.
• Real-Time Condition Management
  
  • Centralized updates for chronic condition details like medications, symptoms, and planned interventions.
• Audit Trail & Signoff Capabilities
  
  • Comprehensive documentation of all changes with digital accountability and transparency.
• Billing Support
  
  • Simplified billing dashboard clearly identifies billable activities.
  • Automatically suggests appropriate PCM codes.
• RPM Integration (Optional)
  
  • Continuous tracking of patient vitals for proactive management.

Step-by-Step: Running PCM with CCN Health

Step 1: Identify and Enroll Eligible Patients

• Identify patients with qualifying conditions.
• Document patient consent digitally through CCN Health.

Step 2: Establish Personalized PCM Care Plan

• Use customizable templates in CCN to create detailed care plans.
• Document treatment goals, medications, interventions, and follow-ups.

Step 3: Continuous Care & Monitoring

• Conduct regular check-ins through CCN's clinical surveys.
• Automatically track time and condition updates in CCN’s multi-access platform.

Step 4: Coordinate and Stay Informed

• Regularly review patient notes, care plan updates, and chronic condition details in CCN to stay aligned and informed.

Step 5: Engage Patients and Caregivers

• Provide education and engagement through CCN’s clinical surveys.
• Foster involvement by clearly tracking goals within personalized care plans.

Step 6: Simplified Documentation & Billing

• CCN automatically documents all interactions and activities.
• Quickly identify billable activities and submit claims seamlessly.

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