CCM vs PCM: A Practical Guide for Clinical and Billing Teams

OnCare360

Sep 11, 2025

Care management services have become a central part of chronic disease management and reimbursement under Medicare. Two of the most widely used programs—Chronic Care Management (CCM) and Principal Care Management (PCM)—share similarities but are designed for different patient populations.

This guide provides a structured comparison of CCM and PCM, outlines compliance requirements, and addresses frequently asked questions.

Executive Summary

CCM supports patients with two or more chronic conditions, focusing on holistic, ongoing management.
PCM supports patients with one serious, high-risk chronic condition that requires intensive monitoring or intervention.
Both programs require documented time, care plans, patient consent, and compliance with CMS rules.
Practices should select the appropriate program based on patient population, care needs, and clinical workflow capacity.

Program Definitions
Eligibility Criteria
CPT Codes and Time Requirements
Care Plan Expectations
Documentation Standards
Clinical Workflow Considerations
Comparative Table: CCM vs PCM
Compliance Checklist
FAQs

1. Program Definitions

Chronic Care Management (CCM): Monthly care coordination for patients with two or more chronic conditions expected to last ≥12 months, posing risk of decline or death.
Principal Care Management (PCM): Monthly care coordination for patients with one serious chronic condition expected to last ≥3 months, requiring focused management.

2. Eligibility Criteria

Program	Eligibility
CCM	Two or more chronic conditions, significant risk, expected duration ≥12 months
PCM	One high-risk chronic condition, active management required, expected duration ≥3 months

3. CPT Codes and Time Requirements

CCM Codes:

99490 – 20 minutes of clinical staff time/month
99439 – Each additional 20 minutes
99491/99437 – Provider personal time
99487/99489 – Complex CCM, 60+ minutes, moderate-to-high complexity MDM

PCM Codes:

99426 – 30 minutes of clinical staff time/month
99427 – Each additional 30 minutes
99424/99425 – Provider personal time (where recognized by payers)

4. Care Plan Expectations

CCM: A comprehensive care plan addressing all conditions, medications, goals, and coordination needs.
PCM: A focused care plan addressing the single high-risk condition (e.g., CHF, oncology, CKD).

5. Documentation Standards

Patient consent (verbal or written) documented in the medical record.
Time logs detailing date, staff attribution, and minutes.
Care plan stored in a shareable, accessible format.
Interventions documented in progress notes.

6. Clinical Workflow Considerations

CCM requires broader coordination across multiple specialties and more complex care planning.
PCM allows a narrower focus, often initiated by specialists managing one high-risk condition.
Both can be paired sequentially (e.g., PCM during oncology treatment, then CCM for ongoing multimorbidity).

7. Comparative Table: CCM vs PCM

Feature	CCM	PCM
Patient Population	≥2 chronic conditions	1 high-risk chronic condition
Duration of Condition	≥12 months	≥3 months
Care Plan	Comprehensive, multi-condition	Focused, condition-specific
Time Requirement	20–60+ minutes/month	30+ minutes/month
Billing Codes	99490, 99439, 99491, 99437, 99487, 99489	99426, 99427, 99424, 99425
Provider Involvement	Clinical staff under general supervision + optional provider time	Similar, with emphasis on condition-specific expertise
Common Settings	Primary care, care coordination teams	Specialty practices (oncology, nephrology, cardiology)

8. Compliance Checklist

Patient consent documented in record
Time logs with staff attribution maintained monthly
Care plan created, stored, and accessible to care team and patient
Documentation distinguishes CCM vs PCM activities
No duplication of services (cannot bill CCM and PCM for same time/tasks in same month)
Internal audits performed regularly
CMS Final Rule reviewed annually for updates

9. FAQs

Q: Can a patient be enrolled in both CCM and PCM?
A: Not in the same month for the same provider. If a patient has multiple chronic conditions, CCM is usually more appropriate. PCM may be used first when one condition requires intensive management.

Q: Can specialists bill PCM?
A: Yes. PCM is often billed by specialists managing a single complex condition, such as oncology or cardiology.

Q: What happens if a patient’s condition profile changes?
A: Patients may transition from PCM to CCM as additional chronic conditions emerge or require management.

Q: Are RPM or RTM billable with CCM or PCM?
A: Yes, if time and scope are distinct. For example, RPM time cannot be double-counted toward CCM/PCM minutes.

Q: What documentation is most important in an audit?
A: Consent, time logs, care plan detail, and clear attribution of staff/provider activities.

Final Note

CCM and PCM are complementary programs that allow practices to capture reimbursement while improving patient outcomes. Correct patient selection, robust documentation, and structured workflows ensure compliance and clinical impact.

Next Step: Download the CCM vs PCM Comparison Checklist or [schedule a consultation] with our care management experts.

Sources: CMS Physician Fee Schedule Guidance 2025–2026; AMA CPT Code Manual; MGMA Care Management Best Practices