Chronic Care Management (CCM) & Principal Care Management (PCM): 2025 CMS Updates and Best Practices

Chronic Care Management (CCM) has become a vital part of healthcare delivery, offering both clinical and financial benefits when implemented effectively. With the expansion of CMS codes, including new Principal Care Management (PCM) codes and fee adjustments, healthcare providers now have more tools to support effective care coordination. However, as more vendors enter the CCM space with software, clinical teams, and billing services, providers must carefully evaluate their partnerships, since billing is performed under the provider’s NPI and they remain accountable for compliance. Understanding CMS guidelines, following best practices, and establishing a robust foundation is essential for a CCM program to be compliant, efficient, and successful.

This webinar will provide a comprehensive overview of the latest CMS changes, including updates to CCM and PCM codes, and offer practical guidance for keeping providers compliant with billing and care management standards. Attendees will explore the role of Principal Care Management in patient care, including its integration into chronic care workflows, and learn how CMS recognizes CCM as a critical element in improving patient outcomes. Dr. Irina Koyfman, DNP, NP-C, RN, will guide participants through current CMS regulations covering Medicare, Federally Qualified Health Centers (FQHCs), preventive services, behavioral health, telehealth, and physician payment policies, providing actionable strategies to proactively maintain compliance while maximizing reimbursement.

Learning Objectives

• Explain the key components and structure of Chronic Care Management (CCM).

• Summarize the evaluation and care planning processes necessary for CCM implementation.

• Identify the essential elements of an Implementation Plan to support compliant CCM programs.

• Review CMS requirements for CCM and Principal Care Management (PCM) services.

• Examine the scope of services required to bill Medicare for CCM and PCM.

• Understand how CCM programs can close care gaps and actively engage patients in their health.

• Recognize compliance risks and challenges associated with CCM and PCM billing.

• Apply best practices to enhance clinical, operational, and financial performance.

• Assess the impact of CCM on practice revenue, patient care quality, and alignment with the Quadruple Aim.

Areas Covered in the Session

• History and evolution of Chronic Care Management (CCM)

• Introduction of the Advanced Primary Care Model (APCM) in 2025

• Definition of CCM and Principal Care Management (PCM)

• Key CCM activities and patient eligibility requirements

• Examples of chronic conditions relevant for CCM services

• Provider responsibilities in initiating and managing CCM

• Consent requirements (written or verbal) and templates

• Development of a comprehensive care plan and documentation standards

• Billing requirements and procedures for CCM and PCM

• Identifying who can bill and who can provide CCM/PCM services

• Roles of clinical staff according to CPT and CMS guidelines

• Compliance considerations, rules, and risk mitigation strategies

• CCM and PCM platforms overview and evaluation criteria

• Common compliance questions: delegation, patient assignment, international staff, and billing scenarios

• Best practices for clinical teams, operational workflows, and patient engagement

• APCM 13 service elements and billing levels (HCPCS G0556, G0557, G0558)

Suggested Attendees

• Nurses, Nurse Practitioners, and Physicians (MD, NP, PA)

• Population Health and Innovation Officers

• Chief Nursing Officers (CNO) and Chief Medical Officers (CMO)

• Billers, Practice Managers, and Office Managers

• Clinical Staff and Nurse Managers

• C-Suite Healthcare Executives

• Specialists and Primary Care Providers

• Healthcare Administrators and Compliance Officers

About the Presenter

Dr. Irina Koyfman, DNP, NP-C, RN

Dr. Irina Koyfman is a Nurse Practitioner and Doctor of Nursing Practice with over 25 years of clinical experience and 15 years in healthcare executive leadership. She is an expert in Patient-Centered Medical Home (PCMH), Home Health, Chronic Care Management (CCM), Remote Patient Monitoring (RPM), transitional care, and care coordination. Dr. Koyfman has founded four successful healthcare ventures, driving operational growth, building high-performing teams, and improving patient outcomes.

As the founder of Affinity Expert, she consults with primary care providers on CCM implementation, providing guidance on clinical, operational, and financial strategies. She is a frequent presenter at national conferences and a recognized Subject Matter Expert in CCM and RPM. Dr. Koyfman actively engages the clinical community through social media groups, offering free education and resources to empower providers and teams. Her commitment to healthcare education extends to volunteer work and board service, reinforcing her dedication to improving patient care and clinical compliance.