Not every high-risk patient has two chronic conditions. Principal Care Management is Medicare's answer for the patient whose single condition — heart failure, COPD, CKD, active cancer — dominates their care. Sansera runs PCM with the same AI care team and the same automatic billing as every other program on the platform.
PCM launched in 2020 to fill the gap CCM left open: the patient with one complex chronic condition expected to last at least three months, with a risk of hospitalization, acute exacerbation, functional decline, or death. It's time-based like CCM — but the trigger is different (one serious condition, not two), the care plan is condition-specific rather than comprehensive, and it's frequently billed by a specialist managing that dominant condition intensively.
PCM is also healthcare's bridge program: a cardiologist runs PCM during six months of heart-failure optimization, then the patient transitions back to the PCP — often onto CCM or APCM. Recognizing and executing that hand-off is where most programs drop the ball. Ours automates it.
| Code | Who performs it | Monthly threshold | ~2025 rate* |
|---|---|---|---|
| 99424 | Physician / QHP personally | 30 min | ~$88 |
| 99425 | Add-on to 99424 | each +30 min | ~$60 |
| 99426 | Clinical staff, directed by physician/QHP | 30 min | ~$68 |
| 99427 | Add-on to 99426 | each +30 min | ~$50 |
*National non-facility averages; localized against your fee schedule in-platform.
| PCM | CCM | |
|---|---|---|
| Conditions required | 1 complex | 2+ chronic |
| Care plan | Condition-specific | Comprehensive |
| Typical biller | Specialist or PCP | Primary care |
| Duration mindset | Episode / bridge (3+ months) | Ongoing |
| Same-month combo | Never with CCM or APCM | Never with PCM or APCM |
If a patient qualifies for both, the right answer is the one that pays more compliantly — and that answer changes month to month. The Smart Billing Engine makes that call automatically, with the full calculation retained for audit.
The AI severity model flags single-condition patients with real risk — recent ED or inpatient utilization, deteriorating trends from remote monitoring, high-risk medications — and proposes them for PCM. Your provider confirms the principal condition; nothing enrolls on AI judgment alone.
Specialty templates (HF, COPD, CKD, oncology support) drafted by AI from the chart, edited and signed by the treating clinician.
The AI Care Coach's check-in protocol matches the condition — weight and symptom trajectory for HF, exacerbation screening for COPD — with deterministic escalation to your team.
The 99424 and 99426 ladders are distinct; the ledger keeps both totals so month-close selects the right one.
When the condition stabilizes against your rules, the engine proposes transition to CCM or APCM, updates the consent scope, and queues the care-plan change — so the patient never falls out of managed care between programs.
Medicare permits different practitioners to bill different care-management programs for the same patient in defined circumstances, with fully separate time and documentation. Sansera detects the concurrent-biller situation and enforces separation — or flags the conflict before a claim goes out.
No. PCPs bill PCM regularly — commonly for a patient whose single serious condition needs focused management before broader chronic-care enrollment makes sense.
A condition expected to last at least three months that places the patient at risk of hospitalization, acute exacerbation/decompensation, functional decline, or death — and typically requires care-plan revision or unusually complex management. Our documentation checker verifies the chart supports it before the code is selected.
CCM, PCM, and APCM are mutually exclusive — every patient, every month, there's one compliant program that pays best, and it changes as the patient changes. RPM and RTM stack on top with rules of their own. The Smart Billing Engine evaluates all of it monthly: eligibility, expected revenue, delivery requirements, and every compliance gate — deterministic rules, never AI guesswork, with an evidence bundle behind every claim.
Thirty minutes. Bring your panel size and payer mix; we'll show you what your care-management program is actually worth, and what it takes to capture it without hiring anyone.
Someone from the Sansera team will reach out within one business day with a custom demo agenda built around your patient mix.