PCPCM Compensation Overview
Physician total compensation is made up of three components: encounters, time and complexity-adjusted panel payments.
For full details on billing in the model, please refer to the PCPCM Operations Manual.
Billing for Encounters
- Utilizes standard fee-for-service (FFS) codes
- PCPCM Business Arrangement (BA) should be used when operating under the PCPCM
- In-basket services are paid at 68.5% of FFS value
- Procedure tray fees remain at 100%
- Out-of-basket services (all other billable codes) are paid at 100%
- Complexity modifiers and BCP payments are not eligible
- RRNP payments apply only to encounter payments, at 100% of FFS value
- As with FFS, these payments are reflected in your Statement of Assessment and are paid weekly
Billing for Time
- Billed in addition to encounter codes
- Uses the Non-Patient Specific Unique Lifetime Identifier (ULI): 10814-7612
- To set this up in your EMR, see our new PCPCM resource, Billing for Time by EMR
- Up to 20% of total time-based billing (per fiscal year) can be billed using the after-hours premium rate
- Physicians should claim time when the majority of patients seen during the day are part of their panel
- Subtract time spent on out-of-basket/uninsured services
- Sample day sheet: How to Calculate Time
- As with encounter payments, these payments are reflected in your Statement of Assessment and are paid weekly (see image below)
- Additionally, a 10% practice management payment is automatically calculated based on time-based PCPCM claims (PC001, PC002, PC003, PC004). This payment is reflected in your Statement of Account and is paid weekly (see image below)
PCPCM Billing Codes for Time
|
Code |
Rate (per 15 min) |
Description |
Max Calls Per Day |
|
Code PC001 |
Rate (per 15 min) $26.25 |
Description Time spent delivering clinical services, between 0700-1700 hours, on weekdays, per 15 minutes. Charting of encounters between patients should be billed as direct time. |
Max Calls Per Day 40 |
|
Code PC002 |
Rate (per 15 min) $26.25 |
Description Time spent delivering indirect care. The patient does not have to be present or have an encounter with the physician on the same day as indirect care. Does not have to be for services which are in the SOMB. |
Max Calls Per Day 44 |
|
Code PC003 |
Rate (per 15 min) $48.18 |
Description Time spent delivering clinical services, under PCPCM, between 5pm-11pm hours on weekdays per 15 minutes. Charting of encounters between patients should be billed as direct time. If the service is after hours, then the charting time is eligible for the afterhours premium. |
Max Calls Per Day 24 |
|
Code PC004 |
Rate (per 15 min) $48.18 |
Description Time spent delivering clinical services, under PCPCM, between 7am-11pm hours on weekends and statutory holidays per 15 minutes. Charting of encounters between patients should be billed as direct time. Urgent calls to patients can be done from home and be claimed using the after-hours premium. Virtual care during this time should be complimentary to in-person care and so virtual care clinics set up in the evenings should not be claimed using PCPCM |
Max Calls Per Day 64 |
Statement of Assessment Sample
The lines highlighted in yellow represent your time-based payments.
Statement of Account Sample
The line highlighted in yellow represents your practice management payments.
