Principal Care Management can give specialty and primary care practices a more structured way to support patients. But putting a PCM program into practice is not as simple. The program has to work in the real world of a busy clinic.
The challenge for many practices is consistency. A patient may receive helpful outreach one month. But without a defined workflow, the next month’s calls, medication follow-up, care-plan updates, and time entries can easily fall through the cracks. That is where a practical PCM implementation checklist becomes valuable. It helps practices turn broad program requirements into repeatable daily actions. Most PCM implementation guidance follows the same core framework and reviews billing readiness each month.
This checklist walks through the 10 practical steps most successful U.S. practices follow when they implement PCM. This will help your team create a workflow that is organized and easier to maintain.
PCM Implementation Checklist: 10 Steps to Get Started
Launching a principal care management program works best when you treat it like a small & repeatable project rather than a one-time billing decision. Most successful practices follow a clear sequence that keeps things simple and compliant.
Below is a practical 10-step checklist drawn from what works in real clinics:
- Confirm Patient Eligibility and Principal Condition
Verify that the patient truly qualifies for PCM before anything else. PCM is designed for patients with a single serious and high-risk chronic condition. The condition is expected to last at least three months and that places them at significant risk of hospitalization, acute exacerbation, or functional decline.
Ask:
- Does the patient have one principal chronic condition that requires ongoing and intensive management?
- Is the condition expected to persist for at least 90 days?
- Has there been an initiating visit within the last 12 months that establishes the need for PCM?
This helps ensure you are focusing PCM resources on the patients who will benefit most.
- Review Exclusions and Overlap with Other Programs
PCM cannot be billed in the same month as certain other care management services for the same patient. Before enrollment, confirm the patient is not currently receiving:
- Home health services
- Hospice care
- End-Stage Renal Disease monthly capitated payments
- Transitional Care Management for the same period
- Another PCM or Chronic Care Management service from a different practice in the same month
Only one practitioner or facility may bill PCM for a given patient in a calendar month. This makes coordination especially important if your patient sees multiple specialists.
- Obtain and Document Patient Consent
CMS requires verbal or written consent before PCM services begin. The consent conversation should clearly explain:
- What PCM includes
- That only one clinician or practice can bill PCM each month
- That standard cost-sharing may apply
- That the patient can stop PCM services at any time
Document this consent in the medical record and the patient’s agreement to proceed.
- Assign a PCM Care Lead and Define Roles
Decide who will own the patient’s PCM program month to month. Many practices have a nurse care manager, a medical assistant with care-management training, or another qualified clinical staff member working under physician or qualified health professional supervision.
Clarify responsibilities such as:
- Conducting monthly PCM calls and outreach
- Updating the disease-specific care plan
- Coordinating with the physician/QHP for clinical decisions
- Tracking time and activities for billing
Clear role assignment prevents gaps in follow-up and makes it easier to train new staff as the program grows.
- Build a Disease-Specific Care Plan
PCM requires a patient-centered & disease-specific care plan focused on the principal condition. It should reflect the patient’s current status, goals and specific risk factors.
The treatment plan should include:
- The principal diagnosis and relevant comorbidities
- Current medications tied to that condition
- Symptom triggers and when to escalate care
- Monitoring schedule
- Patient education topics and self-management goals
- Follow-up cadence and responsible team members
Use this plan as the anchor for every monthly PCM interaction.
- Define Your Monthly PCM Workflow
Map out what a typical PCM month looks like for an enrolled patient. A simple & repeatable workflow reduces missed steps and makes training easier.
A common structure includes:
- Early-month review
- Mid-month outreach
- Care coordination
- Documentation
- End-of-month billing review
If you work with an operational partner like MediRemote, this is where their support can help. Our team handles everything from routine outreach calls to preparing billing-ready summaries so your clinical team can focus on higher-level decisions.
- Track Time and Activities Accurately
PCM is a time-based service. You must document at least 30 minutes of non-face-to-face clinical work in a calendar month focused on the principal condition to bill. Time can accumulate across multiple interactions but must meet the 30-minute threshold before any PCM code is billed.
For each activity, record:
- Date of service
- Staff member who performed the work
- Specific activity
- Start/stop times or total minutes spent
Keep this log separate from other time-based services to avoid double-counting. Clear time tracking is one of the most common audit focus areas for PCM.
- Choose the Right PCM CPT Codes
PCM uses four primary CPT codes. These codes split between physician/QHP time and clinical staff time:
- 99424: First 30 minutes of PCM provided personally by a physician or QHP
- 99425: Each additional 30 minutes by the physician/QHP
- 99426: First 30 minutes of PCM provided by clinical staff under physician/QHP direction
- 99427: Each additional 30 minutes by clinical staff
Select codes based on who is delivering the service and how much total time was spent in the month. Only one set of PCM codes can be billed per patient per month. And the time must be clearly tied to the disease-specific care plan and principal condition.
- Integrate PCM Documentation into Your EHR
Documentation must live where your team already works for PCM to be sustainable. Work with your EHR administrator or IT support to:
- Create a PCM template or note type for monthly care management
- Add fields for time logs, activities and care-plan updates
- Flag PCM patients in your patient list for easy identification
- Build reminders for monthly outreach and end-of-month billing reviews
It becomes much harder to miss key elements when PCM documentation is embedded in your normal workflow.
- Run a Monthly Billing and Quality Review
Run a quick internal review each month before submitting PCM claims:
- Confirm eligibility and that no excluded services overlap in the same period
- Verify that consent is on file and up to date
- Ensure at least 30 minutes of qualifying time is documented for each billed patient
- Check that activities align with the disease-specific care plan
- Match documented time to the correct CPT code
These insights not only support better care but also strengthen your case for PCM as a core part of your practice’s value-based strategy.
Follow these ten steps in order and you will have a compliant & sustainable Principal Care Management program that actually works in the real world of a busy practice.
Tools and Technology Needed for PCM Implementation
You do not need a long list of expensive new systems to run Principal Care Management well. Most practices already have the core pieces in place. Successful PCM programs depend less on staffing alone and more on having the right technology. Below are the core categories practices need before rolling out PCM.
- Certified EHR System
- Care Management Platform
- Remote Patient Monitoring Devices
- Secure Patient Communication Tools
- Time-Tracking and Billing Software
- Population Health / Patient Identification Tools
All-in-One Solutions Like MediRemote
Using separate tools for billing, time tracking, and patient outreach can get complicated. MediRemote brings these tasks together in one platform. We help reduce administrative work for your clinical team.
Conclusion
Launching Principal Care Management does not have to be complicated. When you follow a clear plan of action, the program becomes manageable and sustainable for most practices. The checklist above gives you a practical starting point. Take it one step at a time and adjust as you learn. You can have a PCM program after following the implementation checklist that works in the real world of a busy practice.
MediRemote can help your practice if the operational side still feels heavy. Our team handles the day-to-day outreach, time tracking, and documentation support so your clinical team stays focused on care decisions.
Frequently Asked Questions
How can MediRemote help with PCM implementation?
MediRemote handles the operational pieces. So your clinical team can stay focused on care decisions.
Are there differences in how rural practices implement PCM?
The core requirements are the same. But rural clinics often rely more heavily on phone outreach and may have fewer local specialists to coordinate with
How often should we update the care plan?
Update it whenever there is a meaningful change in the patient’s condition or medications. A formal review at least periodically keeps the plan current and useful.
Is PCM only for Medicare patients?
The formal PCM codes are Medicare Part B services. Some Medicare Advantage and commercial plans offer similar coverage. Verify with each payer.
Do we need special software beyond our EHR?
Most practices manage with their existing EHR if it supports care plans and time logging. Some add simple tracking tools or secure communication options.