Nephrology practices look after patients with CKD, patients with kidney damage and a range of other complex renal conditions. These are typically patients who require a significant amount of ongoing management in terms of medical care, medication, lab monitoring and so on.
Principal Care Management (PCM) is a structured approach to the management of patients with one complex chronic condition which is at high risk of hospitalisation, acute exacerbation, functional decline or death.
Understanding which nephrology patients eligible for PCM will help the practice to identify the right patients, structure their care management services and put in place compliant billing workflows.
In this guide, we are going to explain what is the PCM eligibility criteria in nephrology, what are the qualifying kidney conditions are, patient estimation methods, and documentation requirements
What Is Principal Care Management (PCM) in Nephrology?
In nephrology, Principal Care Management focuses on managing complex kidney conditions that require regular clinical attention. A nephrologist develops a disease-specific care plan and coordinates ongoing services to address the patient’s primary renal condition.
For example, a patient with advanced CKD may need regular kidney function assessments, medication adjustments, electrolyte monitoring, and coordination with other specialists. PCM provides a structured process for managing these responsibilities between scheduled appointments.
The main objective is to prevent complications, maintain disease stability, and reduce the risk of avoidable hospital admissions.
How Is PCM Different From CCM in Nephrology?
Nephrology practices often manage patients with multiple chronic conditions. Understanding the difference between PCM and Chronic Care Management (CCM) helps providers select the appropriate service.
| Feature | PCM | CCM |
| Primary focus | One complex chronic condition | Two or more chronic conditions |
| Condition duration. | At least 3 months | At least 12 months or until death |
| Clinical priority | Managing one high-risk condition | Coordinating care across multiple conditions |
| Monthly time | At least 30 minutes | At least 20 minutes for standard CCM |
| Main objective | Manage a specific high-risk condition | Coordinate overall chronic care |
PCM Eligibility Criteria in Nephrology
Identifying nephrology patients eligible for PCM requires more than reviewing their diagnosis list. Providers must establish that the patient’s condition meets Medicare’s clinical and service requirements. The following criteria help nephrology practices evaluate potential candidates.
A. The Patient Has One Complex Chronic Kidney Condition
An established complex chronic condition is the first requirement for nephrology patients eligible for PCM. Examples of renal conditions include:
- Chronic kidney disease (CKD)
- Advanced CKD
- Chronic kidney failure
- Nephrotic syndrome
- Chronic nephritic syndrome
- Glomerular disorders
- Renal tubulo-interstitial diseases
- Certain forms of toxic or medication-induced nephropathy
There are many complications in these conditions, like progressive kidney damage, impaired filtration, protein loss, electrolyte disturbances, and other complications.
B. The Condition Is Expected to Last at Least Three Months
The second requirement concerns the expected duration of the condition. PCM covers chronic conditions expected to persist for at least three months. Nephrology patients with established CKD often meet the duration component because CKD involves persistent abnormalities in kidney structure or function.
The medical record must support the diagnosis and expected duration. If a patient has acute kidney injury (AKI), they will not automatically qualify for PCM because AKI is sometimes temporary and is not necessarily expected to last for at least three months.
C. The Condition Creates Significant Clinical Risk
A qualifying condition must place the patient at significant risk of serious clinical consequences. Nephrologists can assess this risk through several clinical indicators:
- Declining estimated glomerular filtration rate (eGFR).
- Persistent or worsening albuminuria.
- Recurrent electrolyte abnormalities.
- Difficult-to-control hypertension associated with kidney disease.
- Repeated hospitalizations related to renal complications.
- Frequent medication adjustments.
- Increasing fluid retention or volume overload.
- Progressive loss of kidney function.
These indicators help providers assess disease severity and the need for additional management.
For example, a patient with end-stage CKD, recurrent hyperkalaemia, and a lot of medication titrations would be a far more clinically significant patient than a patient with stable kidney function and no real issues at all.
D. The Patient Requires a Disease-Specific Care Plan
PCM also requires a care plan focused on the qualifying chronic condition.
For nephrology patients, the care plan can include:
- Kidney function monitoring.
- Medication reconciliation and adjustments.
- Blood pressure management.
- Electrolyte monitoring.
- Fluid and dietary management.
- Follow-up laboratory testing.
- Coordination with other treating providers.
- Patient education about kidney disease progression.
- Clinical intervention when concerning changes occur.
The nephrologist determines the appropriate clinical goals and interventions.
E. The Patient Needs Ongoing Clinical Management
The final consideration is whether the patient requires continued management throughout the month.
A patient can need regular communication, care coordination, medication review, and monitoring between office visits.
Important: Medicare PCM requires at least 30 minutes of qualifying services per calendar month. Practices must distinguish between physician/QHP time and eligible clinical staff time when selecting the appropriate code.
Which Nephrology Patients Are Potential PCM Candidates?
Several kidney conditions can create the clinical complexity and management needs associated with PCM. However, nephrologists must evaluate each patient’s individual circumstances before enrollment.
Identifying Nephrology Patients Eligible for PCM requires an assessment of disease progression, clinical risks, and ongoing treatment needs.
Patients With Stage 3b CKD
Patients with Stage 3b CKD have significantly reduced kidney function. At this stage, their eGFR ranges from 30–44 mL/min/1.73 m², which indicates that the kidneys are not filtering blood as effectively as before.
In some patients, kidney function continues to decline with the passage of time. They can also experience increased albumin (protein) levels in urine, persistent high blood pressure, and electrolyte imbalances in the body.
In these complications, regular checkups is required, and proper kidney function monitoring and medication adjustments are required when necessary.
Patients With Stage 4 CKD
Stage 4 CKD involves an eGFR of 15–29 mL/min/1.73 m². These patients have substantially reduced kidney function and often need closer nephrology supervision.
Patients With Stage 5 CKD
Stage 5 is the most advanced stage of CKD. In this stage, patients have an eGFR below 15 mL/min/1.73 m². This means their kidneys have a severely reduced ability to filter blood.
In this stage, patients require intensive renal management. Doctors also discuss dialysis and kidney transplantation. Proper care includes regular laboratory tests, medication management, monitoring symptoms, and coordination with other specialists.
However, dialysis status alone does not establish eligibility. Providers must assess the specific qualifying condition, service requirements, and applicable payer rules.
Patients With Nephrotic Syndrome
Nephrotic syndrome involves significant protein loss through urine, often accompanied by low blood albumin, edema, and elevated blood lipids. When nephrotic syndrome creates significant clinical risk and requires a disease-specific care plan, the patient can qualify for PCM.
Patients With Chronic Glomerular Disorders
Glomerular disorders affect the kidney’s filtering structures. Depending on the underlying condition, patients can experience persistent proteinuria, hematuria, declining kidney function, and progressive renal damage.
Some patients require long-term immunosuppressive treatment, laboratory monitoring, and frequent treatment adjustments. These management needs can support PCM eligibility when the remaining criteria are met.
How to Estimate PCM-Eligible Patients in Nephrology
A reliable estimate requires reviewing patient records, identifying qualifying conditions, evaluating clinical risk, and assessing the need for ongoing care management.
The 2025 United States Renal Data System (USRDS) Annual Data Report provides useful population context. It reports that 17.1% of adults aged 66 years and older with Medicare fee-for-service coverage had diagnosed CKD in 2023.
This figure describes CKD prevalence among older Medicare beneficiaries, not the percentage eligible for PCM.
- Review the Existing Patient Population
- Identify Patients With High-Risk Conditions
- Evaluate Care Management Needs
- Confirm Documentation and Billing Requirements
Estimating a Nephrology Practice’s PCM Population
Estimating the number of Nephrology Patients Eligible for PCM helps practices understand their potential enrollment opportunities. Consider a nephrology practice with 500 active patients. The following example demonstrates how a practice can organize its screening process.
| Screening stage | Patients remaining |
| Total active nephrology patients | 500 |
| Patients with documented chronic kidney conditions | 350 |
| Patients meeting the preliminary clinical-risk screen | 140 |
| Patients requiring ongoing disease-specific management | 90 |
| Patients with documented eligibility and verified billing requirements | 65 |
These numbers are not national eligibility rates or published nephrology benchmarks. The practice identifies 65 patients for potential PCM enrollment after completing its screening process.
The actual number varies according to disease severity, patient population, clinical documentation, payer rules, and available care management resources.
Use this formula to estimate your practice’s potential PCM population:
Eligible PCM patients = Patients with qualifying chronic conditions who meet clinical risk, care management, documentation, and payer requirements.
When practices estimate PCM enrollment opportunities, nephrology chronic condition PCM qualification provides a useful screening framework for distinguishing patients with routine kidney disease management needs from those requiring intensive, ongoing clinical oversight.
What Documentation Is Required for Nephrology Patients Eligible for PCM?
Proper documentation is essential when identifying and enrolling Nephrology Patients Eligible for PCM. The medical record must demonstrate why the patient qualifies and how the practice provides ongoing management.
Nephrology practices must maintain documentation that supports the following elements.
A. Qualifying Kidney Condition
Record the patient’s primary chronic kidney condition and its clinical status.
Include relevant details such as:
- Specific kidney disease diagnosis.
- CKD stage, when applicable.
- Relevant eGFR results.
- Urine albumin-to-creatinine ratio (UACR), when relevant.
- Relevant electrolyte abnormalities.
- Disease progression and associated complications.
The documentation must establish that the condition is chronic and expected to last at least three months.
B. Clinical Risk
The provider must explain why the patient’s condition creates significant clinical risk.
For example, documentation can describe progressive kidney function decline, recurrent hyperkalemia, fluid overload, or previous renal-related hospitalizations.
Avoid documenting only that the patient has advanced CKD. Explain how the condition affects the patient’s health and why continued management is necessary.
C. Maintain a Disease-Specific Care Plan
The care plan must address the qualifying kidney condition.
Include:
- Treatment objectives.
- Medication management.
- Laboratory monitoring schedules.
- Clinical follow-up requirements.
- Patient education.
- Care coordination responsibilities.
- Actions for concerning clinical changes.
The nephrologist must review and update the care plan when clinical circumstances change.
D. Record Monthly Care Management Activities
Practices must maintain records of the services provided throughout each calendar month.
Time records must support the applicable monthly billing code. Practices cannot count routine administrative work or unrelated activities toward PCM time.
E. Patient Consent and Communication
Practice has to take the documented verbal or written consent prior to giving PCM services. The record must show that the patient was informed that the PCM is just for a single chronic condition, and only one practitioner practice may bill for the patient in a calendar month
Which CPT Codes Apply to PCM in Nephrology?
Nephrology practices must select PCM codes according to who performs the services and how much qualifying time they provide during the calendar month.
Medicare recognizes four principal PCM CPT codes:
| CPT code | Description | Time requirement |
| 99424 | Physician/QHP personally performs PCM services | First 30 minutes |
| 99425 | Additional physician/QHP PCM services | Each additional 30 minutes |
| 99426 | Clinical staff performs PCM under physician/QHP direction | First 30 minutes |
| 99427 | Additional clinical staff PCM services | Each additional 30 minutes |
For example, if a nephrologist personally provides 30 minutes of qualifying PCM services during a calendar month, CPT 99424 applies.
If eligible clinical staff provide the first 30 minutes of qualifying services under the required direction, CPT 99426 applies.
Additional time is reported using the corresponding add-on codes when the requirements are met.
Frequently Asked Questions
Are all CKD patients eligible for PCM?
No, not all chronic kidney disease (CKD) patients are eligible for Principal Care Management (PCM)
Does stage 3 CKD qualify for PCM?
Yes, stage 3 chronic kidney disease (CKD) can qualify for Principal Care Management (PCM) under Medicare, provided it meets specific clinical risk criteria.
Can a patient with CKD and diabetes qualify for PCM?
Yes, a patient with both Chronic Kidney Disease (CKD) and diabetes can qualify for Principal Care Management (PCM). However, because PCM is strictly designed to focus on a single, high-risk chronic condition, specific billing and care guidelines apply to how the service is structured.
Can nephrologists provide PCM and CCM to the same patient?
No, the same nephrologist can’t bill for both PCM and CCM for the same patient in the same calendar month. CMS won’t allow PCM and CCM to be billed by the same practitioner in the same calendar month. Different practitioners can bill for each if they meet the requirements.
Conclusion
Identifying Nephrology Patients Eligible for PCM is only one part of running a successful PCM program. Nephrology practices also need operational support to manage patient enrollment, monthly follow-ups, documentation, and ongoing communication.
Mediremote supports healthcare practices with care management operations, helping providers manage administrative responsibilities while retaining clinical decision-making. The team can also help maintain consistent workflows for tracking patient needs and routing concerns to the clinical team.
These services help practices manage the operational demands of chronic kidney disease care without placing every administrative task on nephrologists and their clinical staff.