Talk with us CARE PROGRAM GUIDE · PCM
Principal Care Management
A care team gives extra attention to one serious health problem that needs a complicated treatment plan.
FIRST, THE SHORT ANSWER
What would PCM add to care?
PCM is disease-specific management for one complex, high-risk chronic condition. It is distinct from whole-person CCM and from simple disease education.
A physiologic monitor is not required. Use a care-plan and time-tracking workflow that identifies the condition, practitioner, contributors, and clinical decisions.
PATIENT & PRACTICE FIT
Could this help people you treat?
Potential fit
One condition expected to last at least three months, posing significant risk of hospitalization, deterioration, functional decline, or death and requiring an unusually complex disease-specific management plan.
Check before enrolling
A stable diagnosis without unusual management complexity; under 30 minutes of qualifying monthly work; no disease-specific plan; or no eligible practitioner and initiating relationship.
PATIENT EXPERIENCE
The patient has a focused plan for the serious condition, help with treatment changes and access barriers, and coordinated communication with relevant specialists and caregivers.
SEE IT IN PRACTICE
Care between visits, step by step.
Meet Aisha: her kidney disease needs frequent treatment adjustments and coordination with other clinicians.
The goal: Help Aisha carry out the kidney-care plan and resolve treatment barriers.
Choose a stage to see what the patient, treating practice, and PrimeVital’s agreed team each do.
Qualify the condition
Before enrollment- Patient / caregiver
- Discusses the focused program, consent, and possible costs.
- Treating practice
- Confirms a qualifying high-risk condition and the initiating visit.
- PrimeVital’s agreed role
- Supports intake and identifies coordination gaps.
- What gets recorded
- Condition, duration, risk, complexity, and responsible practitioner.
Illustrative scenario, not a patient record or clinical protocol. Clinical targets, review frequency, staff qualifications, escalation, and service hours are agreed with the treating practice. Clinical decisions stay with qualified personnel.
SAMPLE CARE PLAN
A plan the patient and the team can understand.
Help Aisha carry out the kidney-care plan and resolve treatment barriers.
- Patient task
- Discuss symptoms, medicines, tests, and difficulties following the plan.
- Clinical owner
- The nephrology practitioner directs the disease-specific plan and makes treatment decisions.
- Team follow-up
- Coordinate planned tests, medication questions, appointments, and handoffs.
- Review
- Review the condition, necessary changes, and remaining tasks each month.
After launch: the continuing period
Revisit the disease-specific plan and complexity. Coordinate with the primary-care team rather than duplicate its work. Check the yearly initiating-visit requirement for continuation.
YOUR INVOLVEMENT
Clinical ownership stays with the treating practice.
The agreement names the people, work, coverage hours, records access, and handoffs. Technology and operational support do not transfer clinical or billing authority.
What your clinician does
An eligible physician or other qualified health care professional owns the disease-specific plan and bills the code matching who performs the work.
What supporting staff can do
Clinical staff can contribute to the staff-time pathway under the eligible practitioner’s direction. Practitioner-personal time and clinical-staff time use different codes.
What we can organize with you
PrimeVital can help establish the disease-specific intake, outreach, documentation, and RCM handoffs; the specialist or treating practice directs care.
PrimeVital’s full care arrangement includes applicable devices and a care-management team. The program determines which resources and professional qualifications are needed. Interactly can support front-desk tasks within the agreed scope; 24/7 PrimeVital clinical coverage is not assumed.
REQUIREMENTS BEFORE LAUNCH
Make the pathway ready before enrolling patients.
- Confirm the single condition, risk, initiating visit, and disease-specific care plan.
- Assign a billing practitioner and distinguish practitioner-personal from staff work.
- Record at least the applicable qualifying monthly time without duplicate minutes.
- Check the current continuation and overlapping-service rules.
Detailed operating workflow and technology
- 1
Qualify
Confirm the single high-risk condition, responsible practitioner, initiating visit, and patient consent.
- 2
Plan
Document the disease-specific care plan, treatment goals, and expected adjustments.
- 3
Manage
Coordinate medicines, symptoms, referrals, and clinically necessary changes.
- 4
Reconcile
Record qualifying monthly time by performer; avoid duplicate time or an inappropriate second service.
Technology and records: A physiologic monitor is not required. Use a care-plan and time-tracking workflow that identifies the condition, practitioner, contributors, and clinical decisions.
GETTING PAID
Who receives payment, and what earns it?
Care need, completed services, evidence, and the actual payer determine the claim. A covered service or an enrollment is not the same as collected revenue.
An eligible practitioner bills qualifying PCM work for one complex condition using the practitioner-personal or clinical-staff pathway. A diagnosis or specialty label alone does not earn payment. PrimeVital is paid under its service agreement.
Medicare Part B recognizes PCM for an eligible single high-risk condition. CMS states that fewer than 30 minutes in a calendar month is not billable as PCM and that another initiating visit is required after one year to continue.
Verify each Medicare Advantage, Medicaid, or commercial contract; a specialty-care management arrangement may already compensate similar work.
Original Medicare Part B cost sharing may apply. Confirm secondary coverage and discuss patient responsibility before enrollment.
Payment boundaryPCM focuses on one principal condition; CCM covers multiple conditions. Do not assume both are appropriate for the same work. Distinct services require independent medical necessity and no duplicate time.
2026 code reference and an illustrative service check
For qualifying disease-specific clinical-staff work, check 99426 for the first 30 minutes and the applicable 99427 additional-time pathway. Practitioner-personal work uses different codes. A single diagnosis or ordinary outreach does not establish the service.
These are code-family summaries, not complete descriptors or payment estimates. Check the current code set, payer, clinician, setting, date, unit edits, and required add-on base code.
| Code / pathway | What it describes | Before billing |
|---|---|---|
| 99424 / 99425 | Practitioner-personal PCM time | First and additional 30-minute pathways; count only eligible practitioner work. |
| 99426 / 99427 | Clinical-staff PCM time | First and additional 30-minute pathways under practitioner direction. |
Questions before a claim
Is a single diagnosis sufficient?
No. The risk, complexity, care-plan, initiating, and time requirements must also be met.
Do we need a device?
No. PCM is care management; a separate RPM or RTM program has separate requirements.
FINANCIAL PICTURE
See how participation, collections, and costs change the result.
Start with one supported pathway. Do not multiply every patient by every possible code. Use verified payer terms and the written PrimeVital scope before making a business decision.
Illustrative PCM model
These starting figures are hypothetical. They are not Medicare rates, a PrimeVital quote, or a payment forecast. PrimeVital pilot terms are not modelled automatically. Replace them with your verified contract, service mix, and cost assumptions.
Estimate net after your agreed service fee and other costs
Enter the total fees from your written agreement. No fee is prefilled. Pilot service fees are paid from collections; treatment of denied or insufficient collections must be agreed before launch.
Leave at zero if already included in the service fee. Avoid counting it twice.
Shown separately from recurring operating costs.
35 of 50 patients meet the assumed service requirements.
Illustrative collections before service and practice costs: $3,500. This uses the hypothetical per-patient amount and collection rate above; it is not a code-specific Medicare estimate.
To estimate the amount remaining for the practice, open the cost section and enter the total service fee from a written proposal. We do not invent a PrimeVital price or show a misleading net amount before that is known.
Contribution is before other overhead and taxes. Actual billing uses service-level evidence and rules; this simplified model does not select codes, approve eligibility, or guarantee outcomes. Patient cost sharing and QMB protections must be checked separately.
BENEFITS TO MEASURE
Define success before the first patient starts.
Agree on a baseline and review period. These are measures to track, not promised results or guaranteed payment.
Follow-through
Planned tests, treatment changes, and referrals completed.
Clinical trend
The condition-specific measure selected by the treating practitioner.
Coordination
Unresolved issues and communication with other care teams.
PRIMARY SOURCES
Check the rule before a real claim.
Reviewed October 7, 2026 against current CMS guidance. These guides describe 2026 pathways; proposals for later years are not effective requirements. Coverage, contracts, scope, and patient facts can change the answer.
APPLY THIS TO YOUR PRACTICE
Start with a patient group and a clear question.
Tell us your practice type, payer mix, and workflow. We can map clinical fit, your involvement, available support, launch requirements, and financial assumptions to verify.
DESIGN A PRACTICAL STARTING POINT
Tell us where the workflow is breaking. We’ll show you where to begin.
Send us a message
Continue on your phoneScan to open a pre-addressed email draft.Email contact@theprimevital.com