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March 2025 - PCPCM - Billing and Time

As clinic managers, your support and guidance is crucial for physicians and their teams as they consider adopting and implementing the Primary Care Physician Compensation Model (PCPCM). This session explores how physicians bill for encounters and time and explains how the PCPCM Financial Calculator helps teams evaluate the financial implications of adopting the PCPCM. 

Session Summary

Session Host: Tim Neufeld, AACM Executive Committee 

Guest Presenters: Briana Evans, AMA-ACTT, Graham Vance, AMA-ACTT

Recommended Resources:  

Session Highlights & Themes 

Session Objectives:  

At the end of this webinar, you will be able to: 

  • Describe process for claiming encounters and time
  • Describe how panel payments are calculated
  • Describe the use of the PCPCM Financial Calculator 

Key Takeaways

  • Encounters, time-based payments, panel-based payments (80% from encounters and time)  
  • 113 in-basket codes (94% of Family Medicine claims during 2022/23 fiscal year)
  • Visit codes are time-based and claimed same as FFS
  • Virtual care codes mostly in-basket
  • Rules regarding claims submission, processing and timelines remain the same as FFS 

 

  • Tray fees remain billed at 100% of FFS rate
  • Follows the same rules as FFS in the SOMB 
  • 100% of FFS value for out-of-basket encounters and procedures
  • Billed using your PCPCM BA or FFS BA
  • Out-of-basket = HSCs billed by a Family Physician or General Practitioner not in the list of in-basket codes 

 

  • Recognizes value of patient care time
  • Claims aggregated daily
  • After-hours premium for direct care after-hours
  • Four codes for billing time (PC001, PC002, PC003, PC004)
  • Acknowledgement of the time required of physicians for operating and managing their clinics
  • $105 per hour
  • 10% of hours for direct and indirect care
  • This is paid automatically on a weekly basis pending when claim submissions are done 
  • Billed in 15-minute intervals
  • Claims are submitted for each day of service and must be submitted within 90-days of the service being provided
  • Uses a single non-patient specific ULI for submission of time
  • Cannot be claimed for out-basket services or excluded services – which are paid at 100% FFS
  • No ratio for direct vs indirect care hours
  • For patients attached to PCPCM panel
  • Adjusted for age, sex, CIHI Population Grouper
  • Per patient payment range: $32.87 - $136.73

 

  • Panel uploaded monthly; complexity matrix refreshed annually
  • EMR upload dates vary; changes seen after next upload
  • Demographic mismatch report helps identify missing patients

 

  • Weekly and daily calculators estimate earnings
  • Requires physician's gross community FFS payments, BCP payments, CMGP and CMXC30 modifiers
  • CPAR panel and average annual panel payment auto populated for physicians; clinic managers enter manually
  • Alberta Health updates data every second month

Practical Tips for Clinic Managers 

Efficient Panel Management:  
  • Make CPAR panel management tasks part of a monthly routine
  • Ensure data needed for EMR to upload patients to CPAR is correctly filled out
  • Monitor demographic mismatches and panel conflicts using CPAR reports
  • Use the demographic mismatch report from CPAR to identify and resolve missing patient data
  • Perform EMR searches to locate patients with blank validation dates or non-CPAR patient statuses
  • Look into any potential "bulk actions" your EMR offers to correct issues quickly
  • Contact your EMR vendor if you suspect data migration issues
Optimize Time Claims:
  • Aggregate direct and indirect care time daily and ensure accurate billing using the appropriate codes (PC001, PC002, PC003, PC004)
  • Pay attention to premium after-hours codes for services provided outside regular hours
  • Submit claims within 90 days of service provision using a single non-patient specific ULI
  • Remember that time cannot be claimed for out-basket services or excluded services, which are paid at 100% FFS
Utilize Compensation Calculators: 
  • Use weekly and daily compensation calculators to estimate potential earnings and understand the impact of practice characteristics on compensation
  • Enter necessary data manually if your account is not tied to an individual physician
Panel Payments: 
  • Monitor panel size and complexity matrix updates to ensure accurate payments
  • Understand that payments are adjusted for age, sex, and CIHI Population Grouper
Documentation and Compliance: 
  • Maintain thorough documentation of all claims and ensure compliance with FFS rules
  • Be aware that claims exceeding typical hours may result in review or audit

 

 

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