Chronic Care Management (CCM) and Principal Care Management (PCM) are both transformative care services for patients with chronic conditions. Although, they are both very similar in nature, which could lend way to some confusion among clinicians. As a community-based organization, like a Federally Qualified Health Center (FQHC), which do you choose for your patient population? Follow this guide to get the know-how.


Patient Populations

The first filter to establish when adopting a program, for a generalized patient population or individuals, is how many chronic conditions they have. CCM requires the patient to have at least two or more chronic conditions¹. Thus, this can be adopted as a more generalized care approach. If the data shows that your patients with chronic conditions are the most vulnerable, this is a great approach to introduce across the practice. 


PCM, however, is targeted at patients with one single high-risk or complex chronic condition¹. This lends its way to more individualized care, so if you have a variety of patients that need tailored care more than they need general management, for their health, PCM could be the route to go. 


Clinicians can identify who is eligible for these services during a regular office visit or an Annual Wellness Visit (AWV). Data interpretation through EHRs can also help determine eligibility. AWVs, office visits and Initial Preventive Physical Exam (IPPE) can all be used to initiate these care management services.¹ A hybrid model could also be introduced if your patient mix could benefit from both CCM and PCM.


The number of patients likely to adopt care management services should also be taken into consideration. If the estimated number of patients is low, consider how they could be motivated to enroll via patient engagement and incentives. 



CCM is adaptable for years-long implementation, while PCM may be better suited for shorter term patient-centered care programs. The requirements for CCM include a minimum expected duration of 12 months for the chronic conditions, while PCM only requires a minimum expected duration of three months. PCM’s maximum expected duration of the chronic condition is one year.¹


The end goal of PCM is stabilization of the adverse condition, in which the patient can return to regular primary care appointments without the condition being the sole focus. However, CCM seeks to work in tandem with primary care. 


In regard to building in time into workflows, the difference between billing time for PCM and CCM is only 10 minutes. PCM requires 30 minutes per month of non-face-to-face clinician time, while CCM requires 20.² Elements of care management for both programs can include a systematic needs assessment (medical and psychosocial), the encouragement of preventative services, medication reconciliation, management and promotion of patient self-management.³


The revision of care plans is an important factor to consider as well. PCM requires constant revision of a care plan and input from specialty physicians acting as part of the care team. A CCM care plan does not need to be revised regularly as it lays out a general trajectory, giving more time for care coordination. Along the same lines, the PCM care plan must be disease-specific and outline actionable steps to tackle the specific issue, while CCM can again be implemented with less specificity and target overall well-being. 


Elements of a care plan can include: 

  •     A problem list
  •     Measurable treatment goals
  •     Planned interventions
  •     Medication management
  •     Interaction and coordination with external resources and clinicians¹




Who’s on your team? This can also play a role in what care services you may opt for. The implementation of both services starts with medical staff and leadership ready to transform care. Additional supports can include:


  • Coding and billing staff
  • Health Information Technology staff 
  • Pharmacists
  • Community-based workers
  • Dieticians
  • Health Coaches and nurses¹


If the billing practitioner is a primary care physician, PCM will also require the collaboration between the billing practitioner and one or more specialty physicians. 


PCM can also be billed alongside Remote Patient Monitoring (RPM), so health centers should take into account any staff members needed to organize, analyze and interpret data.¹


“The decision to hire new staff for CCM depends on how many patients a practice determines will likely elect CCM,” says this guide to CCM. First, the practice should determine how many patients are eligible for CCM. Next, the practice should determine how many of those patients will realistically elect CCM. A smaller practice may choose to assign existing staff to coordinate CCM. A larger practice may choose to hire a full-time staff member, such as a registered nurse (RN) care coordinator, to manage CCM, along with other services such as Transitional Care Management (TCM) and Annual Wellness Visits (AWVs). CCM services can be subcontracted to case management companies, but the case management must meet incidents to requirements and should be integrated with the care team.” 

This is applicable to PCM as well. 


Ready to Start? 

Both CCM and PCM provide two different trajectories for patients, although for FQHCs and RHCs, they share the same billing code: G0511.¹ However, they cannot be billed concurrently. Which service you choose comes down to what’s most fitting for the patient(s) and the resources available to you. Certintell helps cover your bases, by:


  • Linking you to a network of specialty physicians
  • Providing health coaches to facilitate care management 
  • Furnishing a fully equipped RPM and patient/provider portal 
  • Giving HIT advice
  • Conducting patient eligibility checks
  • Conducting patient engagement and outreach


All that’s left for you to do is choose what feels best and we’ll help guide you from there. 




¹ “Chronic Care Management – Care Management Medicare Reimbursement Strategies for Rural Providers.” Rural Health Information Hub`, 15 Dec. 2020,


² Clements, Julie. “Learn about Billing Medicare’s New Principal Care Management Codes.” Outsource Strategies International, 14 Feb. 2020,


³ Comagine Health. “CMS Chronic & Principal Care Management Services: Implementation Guidance.” Health Insight, Oct. 2020,