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Key takeaways
- CCM, PCM, APCM, RPM, RTM and BHI are separate Medicare services, each with its own CMS definition, consent and documentation requirements.
- Requirements, codes and payment change every year in the Medicare Physician Fee Schedule, so check the current rules before relying on any summary.
- Data in the EHR can suggest candidates; a clinician decides whether care management is appropriate, and the patient consents.
- Check for overlapping enrollment, including at other practices, before outreach.
Medicare pays for some care between visits through care management and remote monitoring services: Chronic Care Management (CCM), Principal Care Management (PCM), Advanced Primary Care Management (APCM), Remote Physiologic Monitoring (RPM), Remote Therapeutic Monitoring (RTM) and Behavioral Health Integration (BHI). Many practices have patients who could be considered for these services but were never reviewed, because no one has time to read every chart. A candidate list, reviewed by a clinician, solves the finding problem without adding staff. It never decides eligibility on its own.
Before you rely on this guide. It is general information, current to late 2026, and it is not billing or legal advice. CMS updates these services every year through the Medicare Physician Fee Schedule final rule, including which codes exist, their time and documentation requirements, which services can be billed together and how they are paid. Check the current Physician Fee Schedule and the CMS Care Management pages on cms.gov, and confirm with your billing and compliance team, before enrolling anyone. Commercial and Medicare Advantage plans may follow different rules.
How does CMS describe each program?
The summaries below paraphrase how CMS describes each service. They leave out billing codes and payment on purpose, because both change annually and should be taken from the current fee schedule.
| Service | How CMS describes the patient and the service | What to check in the current rules |
|---|---|---|
| CCM, Chronic Care Management | Patients with two or more chronic conditions expected to last at least 12 months, or until death, that place them at significant risk of death, acute exacerbation or decompensation, or functional decline. Requires a comprehensive care plan. | Initiating visit, consent, care plan elements, time thresholds |
| PCM, Principal Care Management | Care management focused on a single complex chronic condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline or death. Uses a disease-specific care plan. | Consent, care plan, which practitioner bills |
| APCM, Advanced Primary Care Management | Monthly services introduced for 2025 for practitioners who provide advanced primary care and serve as the continuing focal point for all of a patient's needed services. Billed monthly and tiered by patient characteristics. | Practice capability requirements, consent, interaction with CCM and PCM |
| RPM, Remote Physiologic Monitoring | Collection and analysis of physiologic data, such as blood pressure or weight, from a medical device that meets the FDA definition, for a patient with an acute or chronic condition. | Established patient relationship, device and data-day requirements, consent |
| RTM, Remote Therapeutic Monitoring | Monitoring of non-physiologic data, such as therapy adherence, therapy response, or musculoskeletal or respiratory status. | Which conditions and devices qualify, time requirements |
| BHI, Behavioral Health Integration | Care management for behavioral health conditions delivered within a medical practice, including the Psychiatric Collaborative Care Model. | Care team roles, consent, time requirements |
CMS also publishes plain-language booklets on several of these services through the Medicare Learning Network, linked from its care management pages on cms.gov.
What makes a patient a candidate for review?
A candidate is a patient whose record contains signals that a clinician may want to consider. None of these signals determines eligibility.
- Conditions. Chronic conditions on the problem list or in recent encounter diagnoses. Examples from specialty care include chronic kidney disease in nephrology, heart failure or atrial fibrillation in cardiology, and COPD in pulmonology. For CCM the CMS description involves two or more qualifying conditions; for PCM, one complex condition.
- Recent care with the billing practitioner. CMS sets visit requirements that differ by service. For CCM, for example, CMS requires an initiating visit for new patients and for patients not seen by the billing practitioner within the prior year. Check the current requirement for each service rather than assuming one rule fits all.
- Coverage. Medicare Part B, or another plan that covers the service. Cost sharing may apply and has to be explained to the patient.
- No conflicting enrollment. The patient may already be enrolled in the same or an overlapping service with your practice or another one.
- Prior decisions. A clinician may already have decided against enrollment, or the patient may have declined.
How do programs overlap?
CMS sets rules about which of these services can be billed for the same patient in the same period, and time spent on one service generally cannot be counted toward another. Some combinations have been permitted when the requirements for each are met; for example, CMS has allowed RPM alongside CCM or PCM. CMS has also said that only one practitioner can bill CCM for a patient in a given calendar month, which matters when a primary care practice and a specialist both see the same patient.
Because these rules change, the practical step is simple: check current enrollment, here and elsewhere where you can, and confirm the current combination rules with your billing team before outreach. Asking the patient is part of that check, since outside enrollment may not appear in your EHR.
Why should a clinician review every candidate?
Eligibility signals are suggestions, not determinations. A patient with the right codes may be in hospice, may be managed by another specialist, or may simply not benefit. A clinician reviews each candidate and either approves the patient for outreach or marks them not appropriate, with a reason. Not-appropriate decisions should hold for a set period the practice chooses, so the same patient does not come back every week.
Clinicians also decide which service fits. A patient with one dominant condition managed by a specialist may fit PCM better than CCM; a patient whose blood pressure is the main concern may be considered for RPM. Those are clinical judgments, and a candidate list should present the evidence, not the answer.
What about consent?
CMS requires patient consent for these services, documented in the medical record. For CCM, CMS describes informing the patient about the availability of the service, that cost sharing may apply, and that they can stop at any time. Consent can be verbal or written, depending on the service and current rules. The usual flow is: clinician approves, then an MA, nurse or clinician explains the service and any cost sharing, and records consent before enrollment.
How do you run this without adding staff?
- Generate candidates from data already in the EHR, refreshed regularly, with the signals for each patient shown side by side.
- Batch the clinical review. A clinician can review a short list quickly when the problem list, recent visits, coverage and current enrollment are on one screen.
- Combine the consent conversation with other contact, such as a recall call or an upcoming visit, rather than a separate cold call.
- Hand enrolled patients to whoever delivers the service: your own care team or a partner such as the HealthArc care team.
Track a short funnel each month: candidates identified, reviewed, approved, declined with a reason, consented and enrolled, plus the time from identification to review. Those counts show where the process stalls without putting a dollar figure on any patient.
How Nuvory helps
Care Management Intelligence reads problem lists, visits and coverage, checks for services already billed and routes candidates to clinical review. It identifies potentially eligible patients only. Nothing is enrolled without clinician approval and patient consent, and the practice's billing team remains responsible for checking current CMS requirements. For other places where planned care slips, see the most common revenue leaks in specialty practices.
Frequently asked questions
Does a candidate list mean the patient is eligible?
No. A candidate list shows patients whose records contain signals a clinician may want to review. Eligibility depends on CMS requirements in force at the time, the clinician's judgment and the patient's consent. The list only decides who gets looked at.
Can a patient be in CCM and RPM at the same time?
CMS has allowed RPM to be billed alongside CCM or PCM when the requirements for each are met, with time counted only once. These rules can change each year, so confirm the current position in the Physician Fee Schedule with your billing team.
Does Nuvory enroll patients automatically?
No. Nuvory suggests candidates. A clinician approves or declines each one, and the patient must consent before enrollment. Your billing team confirms current CMS requirements.
What is APCM?
Advanced Primary Care Management is a set of monthly Medicare services that CMS introduced for 2025 for practitioners who provide advanced primary care and act as the continuing focal point for a patient's needed services. Check the current Physician Fee Schedule for codes and requirements.