The needs of patients do not stop when they leave the clinic. A patient may have medication-related complications or other serious conditions that require proper care. The team has to review laboratory updates, talk to primary care providers, coordinate with pharmacies, and respond to changes before the next patient visit.
Principal Care Management (PCM) gives eligible specialty practices a structured way to organize and document non-face-to-face care for a patient with one complex, high-risk chronic condition.
For practices that want to expand care without adding administrative costs, PCM for nephrology practices offers a practical operating model. Mediremote can support patient outreach, documentation, time tracking, and routine coordination behind the scenes.
Why PCM for Nephrology Practices is a Strong Fit
There are other diseases associated with kidney disease. Like blood pressure, diabetes, and anemia. These diseases play a major role in kidney disease progression. Small changes make no difference at all. If the patient does not get timely support, then it can cause problems.
The patient is consulting so many specialists at a time, such as a family doctor, Cardiologist, dietitian, etc
Each specialist may have their own patient-related information. If there is no proper pathway, changes in medication, referrals, and concerns may be missed.
Using Principle Care Management in practice ensures continuity of care.The care coordinator can call the patient to check what has been agreed and communicate any issues with the nephrology team. The practice can then make sure they are following the patient’s care plan.
This can be very beneficial to patients who frequently experience changes to their medication, poor adherence, low health literacy, or live far away from the practice. It can also be beneficial to those who frequently transition between outpatient and hospital.
PCM Benefits for Nephrology Practices
The benefits of PCM for nephrology practices come from creating a consistent process around care that may otherwise be handled informally. It creates value when the practice uses a documented, patient-centered workflow to support a high-risk condition and connect each activity to the care plan.
1. More consistent follow-up between visits
A structured PCM program can help the practice maintain regular contact with eligible patients. The care team can discuss symptoms, medication questions, appointment needs, and barriers to treatment. Consistent outreach can help the patient understand what to do next instead of relying on memory.
2. Earlier identification of care gaps
Between visits, coordinators screen for missed doses, edema, dietary non-adherence, and medication confusion. Findings are documented and escalated to the nephrology team, who decide whether to educate, adjust therapy, order labs, schedule a visit, or arrange urgent evaluation.
PCM for nephrology practices does not guarantee earlier diagnosis or prevent complications. Its value is in creating a structured process that can help the practice identify and communicate relevant information in a timely manner.
3. Better medication coordination
Between visits, the coordinator reconciles the patient-reported regimen against the active medication list, flags refill gaps and adherence problems, records side effects, and sends discrepancies to the prescriber. Dose and therapy changes remain with the clinician.
The coordinator does not change treatment independently. The nephrologist or another qualified clinician makes that decision.
4. Stronger patient engagement
Many patients with CKD do not feel symptoms until the disease has advanced. Education and repeated reinforcement can help patients connect daily actions with long-term kidney health. PCM for nephrology practices outreach can support questions about blood pressure, glucose, sodium, and warning signs.
A patient who feels heard may become more willing to report problems and participate in the care plan. That engagement supports the broader goals of nephrology care, even though a PCM program alone cannot control every clinical outcome.
5. Improved coordination across providers
The nephrology team can use PCM documentation to record communication with primary care, cardiology, endocrinology, pharmacies, laboratories, and other services. Better coordination can reduce duplicate questions, clarify responsibility, and help the patient receive a more connected experience.
6. More efficient use of clinical staff
Physicians and nurses often spend valuable time chasing missing information, making routine calls, updating lists, and preparing documentation. A service partner can handle defined operational tasks while the practice retains oversight of clinical decisions.
Building a PCM Program for Nephrology Patients
The PCM programme for patients with nephrology problems begins with selection based on a clinical objective. It is not necessary for the practice to take on every patient just because they have chronic kidney disease. Instead, the team focuses on those individuals who have one high-risk condition and need continued specialized care.
The practice must assess issues relating to clinical appropriateness, payer requirements, patient consent, cost-sharing, and the patient’s willingness to take part. Once the practice has identified an eligible patient, the workflow should contain the following elements.
Establish the clinical baseline
Main conditions, risk factors, and the signs that need to be escalated must be recorded by the nephrologist. The care plan must tell what the patient has to do, and what the nephrology team has to review.
Obtain consent and explain the service
Patient has to know that PCM means continuous care management, which is not face-to-face. It means the practice will contact them, and information will be used in different ways,
Create a communication schedule
The practice must specify how often and what kind of contact should be made. In some cases, a structured monthly call will be necessary, while in other cases extra contacts will be needed according to the patient’s condition and care plan. The workflow also needs to have a procedure for dealing with missed calls and urgent symptoms.
Connect PCM with remote monitoring when appropriate
PCM can be used to deliver disease-specific care. RPM includes physiological data collected from within the home (such as BP and weight) using an approved device. It should only be used if the data will directly impact treatment, and this should be set by defining the escalation thresholds in your care plan.
Document every relevant activity
The practice should maintain a clear record of care-plan updates, patient contacts, coordination with other providers, medication discussions, clinical escalations, and time spent. Good documentation supports continuity of care and helps the practice demonstrate that billed services met applicable requirements.
Remote Monitoring Nephrology Outcomes
Outcome measures for remote monitoring in nephrology can include a variety of outcomes, including blood pressure, engagement, admission rates, medication adherence, quality of life, and health utilisation. Some of this can be achieved using PCM if appropriate outreach and meaningful data are provided.
Measures which may be useful include:
- Percentage of patients with an updated care plan.
- Identification and resolution of medication errors.
- Timely completion of lab work.
- Blood pressure changes with RPM.
- Weight or symptom changes raised to the clinical team.
- Appointment non-attendance and follow-up completed.
- ED follow-ups or admissions.
- Patients feeling more confident and satisfied.
- In-house staff time required; in-house aims accepted, complete documentation and trends of denials.
The Nephrology PCM Revenue Opportunity
It comes from providing qualifying PCM services to patients and documenting them. It is important to distinguish this from simply turning routine care coordination into a billable service. A practice cannot bill PCM merely because staff communicate with a patient or spend time coordinating care.
The service must satisfy the applicable requirements, including patient eligibility, the qualifying chronic condition, care planning, required service elements, time requirements, documentation, and applicable payer rules.
PCM CPT Codes and Time Thresholds
| CPT | Furnished by | Time per calendar month |
| 99424 | Physician/QHP | First 30 minutes |
| 99425 | Physician/QHP | Each additional 30 minutes |
| 99426 | Clinical staff, under physician/QHP direction | First 30 minutes |
| 99427 | Clinical staff, under physician/QHP direction | Each additional 30 minutes |
Because payment amounts and coverage rules can change, practices should verify current Medicare and payer-specific requirements before establishing a reimbursement model. A structured PCM for nephrology practices program can help the practice identify appropriate patients, establish a repeatable workflow, document qualifying activities, and track time.
The financial opportunity should also be evaluated alongside the costs of running the program. Practices should consider staffing, technology, patient participation, administrative time, payer mix, denied claims, and clinical oversight. The goal of PCM for nephrology practices should be sustainable care delivery rather than billing volume alone.
A Practical Launch Plan for Nephrology Practices
Practices starting PCM for nephrology practices can begin with a focused pilot rather than immediately enrolling a large patient population.
Step 1: Define the Clinical Focus
Firstly, you need to define the chronic condition and clinical goals of the program. This will ensure that you know who should be included and what clinical care management needs should be addressed.
Step 2: Identify Eligible Patients
Use the practice’s clinical criteria and applicable Medicare or payer requirements to identify appropriate patients. Having CKD alone should not be used as the sole reason for enrollment.
Step 3: Build the Care Plan
Define what clinical goals and interventions should be used. Who is responsible? How will communication happen? What escalation processes?
Step 4: Establish the Documentation Workflow
How will you record communications and coordination? What time is being spent? How will the care plan be updated? What clinical escalations have occurred?
Step 5: Train the Team
Everyone must understand their responsibilities. The practice should know which tasks can be done by operational staff, which by clinical staff (under the applicable requirements), and which issues need to be reviewed by a clinician.
Step 6: Monitor Program Performance
When you are starting a new service, you have to focus on these things in the starting months.
- How many patients are participating in the program
- How many communications are completed, and how many are documented
- How many issues need specialist consideration
- How many patient follow-ups and billing
Step 7: Scale Carefully
When the program starts working smoothly and everything is under control, then the practice can decide whether there is a need to expand the PCM for nephrology practices program.
How Mediremote Supports Nephrology Practices
Mediremote works as an operational partner for the practices that are launching or expanding PCM, RPM, or CCM but don’t want their internal teams work on it. Mediremote can help in making routine calls, making the patient list and documentation that can be checked by practice later.
For nephrology, that support can complement a care plan built around CKD, hypertension, diabetic kidney disease, home dialysis coordination, or another high-risk condition selected by the practice.
Mediremote’s coordinators can identify patient-reported concerns, missing information, or readings that require attention. This division of responsibility helps the practice extend patient contact without turning a software dashboard into a substitute for clinical judgment.
FAQs
Can a nephrologist bill PCM and CCM in the same month for the same patient?
No, a nephrologist cannot bill Principal Care Management (PCM) and Chronic Care Management for the same patient in the same month
Is patient consent required?
Yes, and it should be documented along with a discussion of possible cost-sharing.
Can PCM and RPM be used together?
Yes, when each service independently meets its requirements, and the data supports the care plan.
Who can furnish the time?
Physicians/QHPs for 99424-99425, and qualified clinical staff under direction for 99426-99427.
Conclusion
A Patient Care Management approach can be used in a nephrology practice to ensure that patients suffering from one complex and high-risk renal issue are managed effectively between consultations. This will help ensure consistency of care, better medication management, highlight any gaps in the patient’s care, increase patient involvement, and ensure good organisation for your practice.
Mediremote can help your nephrology practice implement this by helping with patient communication, coordination, record-keeping, and time management. This will therefore help doctors stay in control of patient care whilst reducing the administration involved in managing a PCM. Visit Mediremote to explore a more manageable approach to continuous chronic-care support.