Principal Care Management (PCM) was introduced by Medicare in 2020 to extend Chronic Care Management (CCM) services to patients with one chronic condition expected to last at least 3 months or longer, or until end of life. PCM patients may have multiple chronic conditions, though the provider will be focused solely on one. PCM can be performed by clinical staff or other certified healthcare professionals (CHPs). The current CPT codes for PCM are 99424, 99425, 99426 and 99427. CPT codes 99426 and 99427 are utilized for care coordination services performed by clinicians.
Principal Illness Navigation (PIN) was introduced in the 2024 Physician Fee Schedule (PFS) Final Rule. It was created to help patients with a serious condition navigate the healthcare system, which could be due to socioeconomic disadvantages or barriers to care. This pertains to navigating serious conditions including cancer, mental illness, behavioral health conditions and substance use disorder (SUD). Services can be provided by trained patient navigators or certified peer specialists under the HCPCS codes G0023, G0024, G0140, and G0146. G0023 and add-on code G0024 are for certified or trained auxiliary personnel while G0140 and G0146 are designated for “peer support” by the certified or trained auxiliary personnel specifical for behavioral health conditions.
While Principal Care Management is primarily used for care coordination outside the four walls of a physician’s office to address mainly clinical care needs, Principal Illness Navigation is designed more to address the Social Determinants of Health (SDoH) and barriers to care that can occur with certain conditions. Peer support can be especially helpful for patients navigating conditions like substance use disorder, as peer navigators can utilize their lived experience for assistance.
Both CMS programs aim to improve gaps in care by helping patients receive the extra support needed to properly manage difficult conditions.
References
MM13452 – Medicare Physician Fee Schedule Final Rule Summary: CY 2024 (cms.gov)
