Service · PCM
Principal Care Management
Focused, single-condition management for high-impact chronic diagnoses.
Overview
What PCM looks like in practice
Principal Care Management is built for patients whose care centers on a single high-risk chronic condition — advanced CKD, heart failure, or COPD, for example — where focused, condition-specific attention makes the biggest difference.
Our clinical team works from the specific care plan tied to that one condition: tracking symptoms, medication response, and red flags unique to the diagnosis, and coordinating closely with the treating specialist.
PCM complements rather than duplicates CCM — many practices run both, applying each to the patients it fits.
How it works
Confirm eligibility
We help confirm the patient's single high-risk condition qualifies for PCM.
Build the condition-specific plan
A focused care plan is developed around that one diagnosis.
Monthly condition check-ins
Structured outreach tracks symptoms and treatment response for that condition.
Specialist coordination
We keep the treating specialist looped in on changes and concerns.
Document & bill
Time and clinical detail are logged against PCM billing codes.
Who it's for
- Patients managed primarily around one complex chronic condition
- Specialist practices wanting structured non-visit management for their sickest patients
- Primary care practices co-managing a single dominant diagnosis with a specialist
Key benefits
- Condition-specific care plan built around the primary diagnosis
- Monthly clinical time dedicated to that condition's management
- Tight coordination between primary care and specialty teams
- Billing documentation aligned to PCM-specific CPT codes
Billing & compliance
PCM documentation tracks the condition-specific time and complexity thresholds CMS requires, distinct from CCM's multi-condition framework.