What Is Chronic Care Management (CCM)?
Definition and Purpose
Chronic Care Management (CCM) is designed for patients with multiple chronic conditions, providing comprehensive care coordination to improve outcomes and reduce hospitalizations. In 2025, CCM is supported by the CMS Advanced Primary Care Management (APCM) codes, which bundle CCM with other services to streamline care for complex patients CMS, 2024.
Eligibility Criteria
Patients qualify for CCM if they have two or more chronic conditions expected to last at least 12 months or until death, placing them at significant risk of acute exacerbation, functional decline, or death. Common conditions include diabetes, hypertension, and heart disease.
Billing and Reimbursement
CCM services are billed using CPT codes like 99490 (20 minutes of clinical staff time) and 99491 (30 minutes by a physician or qualified professional), with additional codes for extended time. The 2025 CMS Fee Schedule also introduces APCM codes (HCPCS G-codes) that bundle CCM with other care management services, reducing administrative burden and enhancing reimbursement for comprehensive care CMS, 2024.
What Is Principal Care Management (PCM)?
Definition and Purpose
Principal Care Management (PCM) focuses on patients with a single high-risk chronic condition requiring intensive, condition-specific care. PCM aims to manage and coordinate care for this condition, which often needs frequent monitoring and adjustments.
Eligibility Criteria
PCM is suitable for patients with one complex chronic condition expected to last at least three months, posing a significant risk of hospitalization, exacerbation, functional decline, or death. Examples include advanced heart failure, uncontrolled diabetes, and severe asthma.
Billing and Reimbursement
PCM services are billed using CPT codes like 99424 (30 minutes by a physician or qualified professional) and 99426 (30 minutes of clinical staff time), with additional codes for extended time. In 2025, PCM also benefits from the APCM framework, which supports targeted care management for high-risk patients CMS, 2024.
Key Differences Between CCM and PCM in 2025
Scope of Care
Chronic Care Management
- Holistic Approach: CCM takes a comprehensive approach, addressing all of a patient’s chronic conditions. For example, a patient with diabetes and hypertension benefits from a unified care plan that considers their overall health, lifestyle, and social determinants.
- Key Services: Includes care planning, medication management, patient education, behavioral health integration, and social support services. When paired with RPM, CCM helps patients achieve better control of their conditions, reducing ED visits.
Principal Care Management
- Specialized Focus: PCM targets a single high-risk condition, such as advanced heart failure in a cardiology practice. It involves a disease-specific care plan with frequent monitoring and adjustments.
- Key Services: Includes condition-specific monitoring, specialist coordination, patient education, and emergency planning. RPM enhances PCM by providing real-time data, enabling early interventions that prevent ED visits.
Care Coordination
Chronic Care Management
- Comprehensive Coordination: CCM involves integrated care teams, including primary care providers, specialists, nurses, pharmacists, and social workers. For example, a patient with heart disease and COPD benefits from coordinated care across specialties, supported by HealthSnap’s platform, which offers over 80 EHR integrations for seamless data sharing.
- Patient Engagement: CCM emphasizes 24/7 access to care teams, often through telehealth, ensuring patients and families are engaged in their care plans.
Principal Care Management
- Focused Coordination: PCM centers on the specific condition, often led by specialists (e.g., cardiologists for heart failure). It involves frequent communication with the care team, including nurses and pharmacists, to adjust treatments as needed.
- Targeted Support: PCM provides condition-specific education and emergency planning, ensuring patients know how to manage exacerbations and avoid ED visits.
Impact on Patient Outcomes and ED Visits
In 2025, both CCM and PCM, when paired with RPM, significantly improve patient outcomes and reduce ED visits. For cardiology practices, CCM and PCM help patients with conditions like hypertension and heart failure achieve better control, as highlighted in our 2025 Cardiology Clinical Outcomes Report. Beyond cardiology, HealthSnap supports nephrology, endocrinology, and bariatric specialty groups, helping patients manage kidney disease, diabetes, and obesity-related challenges, leading to fewer emergencies and better quality of life.
Implementation and Best Practices for CCM and PCM in 2025
For Healthcare Providers
Providers should assess their patient population to determine the right mix of CCM and PCM services, integrating RPM to enhance monitoring and outcomes. Accurate documentation and billing practices are crucial to meet CMS guidelines and maximize reimbursements, especially with the new APCM codes.
Technology Integration
HealthSnap’s platform streamlines CCM and PCM implementation with tools for care coordination, patient engagement, and billing compliance. With over 400 Licensed Nurse Practitioners (LNPs) and HITRUST certification, HealthSnap ensures secure, efficient care delivery.
Patient Education
Educating patients about CCM and PCM benefits is key to engagement. Providers should highlight how these programs, supported by RPM, help manage chronic conditions, reduce ED visits, and improve overall health.
Choose HealthSnap for Proactive Patient Care
At HealthSnap, we empower healthcare providers to leverage CCM, PCM, and RPM effectively to improve care for patients with chronic conditions. Our patient-centered approach ensures compassionate care, as one Prisma Health patient shared: “HealthSnap’s calm guidance and check-ins make me feel safe and supported, helping me manage my health without fear.” Across our programs, patients report feeling more confident, with many adopting healthier habits that enhance their well-being.
For healthcare leaders, our programs deliver measurable results: better patient outcomes, fewer ED visits, and new revenue opportunities. Ready to see how HealthSnap can improve care for your organization?
Schedule a free demo with our team to learn how we can support your health system, ACO, provider group, or specialty practice.
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