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PCPCM Billing Basics

This guide provides physicians and clinic teams with a quick reference on billing for encounters and time in the PCPCM, along with examples of weekly statements. 

PCPCM Compensation Overview 

Compensation under the Primary Care Physician Compensation Model (PCPCM) consists 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 Time

PCPCM Billing Basics

Billing for Encounters

PCPCM Billing Basics

Weekly Statement Guide

PCPCM Billing Basics

Payment Schedule

PCPCM Payment Schedule

Billing for Encounters

  • PCPCM utilizes roughly 94% of standard fee-for-service (FFS) codes. They are referred to as In-basket services, prorated at 68.5% of FFS value
  • All other billable codes are considered out-of-basket services and are paid at 100% of FFS value 
  • Procedure tray fees are paid at 100% value
  • Complexity modifiers and BCP payments are not eligible
  • RRNP variable rate payments apply only to encounter payments, at 100% of FFS value 

Billing for Time

General Time Billing Rules

  • Billing for time requires the Non-Patient Specific Unique Lifetime Identifier (ULI): 10814-7612. To set this up in your EMR, see Billing for Time by EMR
  • Physicians can claim time, including time with out-of-province patients, when the majority of patients seen during the day are part of their panel
  • Direct Care Codes (PC001, PC003 & PC004) cannot be claimed for time spent on out-of-basket services, excluded services and encounters with out-of-country patients. To avoid double recovery, track and subtract time spent on excluded services before submitting claims.
  • Up to 20% of total time-based billing per fiscal year can be assigned to premium-rate Direct Care Codes (PC003 & PC004) 
  • Direct Care Codes correspond with when the patient encounter took place 
    • E.g. If charting between after-hour appointments, direct care time can only be claimed for charting if the associated encounter occurred that evening 
  • Submitting more than one claim for the same PCPCM time code in a single day results in rejections. Physicians should submit the time code only once per day, ensuring the claim accurately reflects the total number of calls and time. If additional time must be recorded after the initial submission, submit a Change claim (Action Code C) to update the number of calls.
  • Sample day sheet: How to Calculate Time
  • Holidays are defined by the SOMB Governing Rules

PCPCM Time Codes, Usage & Rates 

Time Code Usage Rate (per 15 minutes)
Direct Care

PC001

Monday - Friday
7:00 a.m. - 5:00 p.m.
excludes holidays

Max calls per day: 40

 $26.25
Indirect Care

PC002

Unrestricted

Max calls per day: 44

$26.25
After-hours Direct Care

PC003

Monday - Friday
5:00 p.m. - 11:00 p.m.
excludes holidays

Max calls per day: 24

 $48.18
Weekend & Holiday Direct Care

PC004

Weekends & Holidays
7:00 a.m. - 11:00 p.m.

Max calls per day: 64

 $48.18

 

PCPCM Time Codes & Eligible Activities 

  • With PCPCM, virtual care should be a complement to in-person care. Virtual-only care clinics cannot use PCPCM codes (see clause 2.3 of the Ministerial Order and CPSA guidelines)
  • Phone calls to patients are considered direct care and can originate from the clinic or the physician's home.

Time Code & Usage

Eligible Activity 
Direct Care

PC001

Direct care to patients

  • in-person  
  • video conference 
  • phone 


Charting between appointments that took place between 7:00am - 5:00 p.m. on weekdays
Indirect Care

PC002

Indirect care  

  • Reviewing labs, consultations with specialists, and completing referral forms/letters
  • Batch charting after the clinic day is over
  • Asynchronous communication with patients, including secure messaging, email, etc
  • Completing forms (excluding third-party forms or forms related to paid services) 
  • Case management activity between providers, where the patient or family members aren’t involved 


The patient does not have to be present in the clinic or have an encounter with the physician on the same day

Claims are not limited to services found in the SOMB
After-hours Direct Care

PC003

Direct care to patients  

  • in-person
  • video conference
  • phone (urgent)


Charting between appointments that took place between 5:00 p.m. - 11:00 pm on weekdays 
Weekend & Holiday Direct Care

PC004

Direct care to patients 

  • in-person  
  • video conference
  • phone (urgent)  


Charting between appointments that took place on weekends and holidays between 7:00 a.m. - 11:00 p.m.

 

Weekly Statement Guide

Statement of Assessment Sample

Lines highlighted in yellow represent your submitted time-based codes and payments.

 

Statement of Account Sample

The areas highlighted in yellow represent your Clinic Practice Management payments (Administration) - a 10% top-up and Monthly PCPCM Panel Complexity payments. 
Practice Management payments are calculated based on your approved PCPCM time codes. 
Click here for more information on how your Panel Complexity Payments are calculated. 


 Explanatory Codes

Code 

 Description
99C Reflects PCPCM discounted rate for in-basket codes paid at 88.5% of FFS value 
99B

*When time-based codes are submitted with an FFS BA, they are rejected. 
99D *When the wrong ULI is used, claims are rejected.


*Physicians can resubmit rejected claims within 90 days of when the claim last appeared as rejected on their Statement of Assessment.