The PCM codes should be reported by patients with one serious chronic condition that has lasted at least three months and is being managed by establishing, implementing, revising, or monitoring a specific care plan for that particular disease.
As of 2020, CMS has developed two codes for principal care management, G2064, and G2065. Four new CPT codes will be introduced in 2022.
There is a distinction between 99424 and 99425 for physicians, other qualified health care professionals, or clinical staff time if the physician has E/M in their scope of practice. There is a distinction between 99426 and 99427 for staff time when the physician is directly involved in the care of a patient with E/M.
What is Principal Care Management?
Patients with a single, complex chronic condition are managed with these time-based codes. These codes are similar to chronic care management services in that they involve establishing, implementing, revising, and monitoring a patient’s care plan.
Medicare Physician Fee Schedule (MPFS) for 2022 was released by CMS on November 2, 2021. It included five new CPT codes for Chronic Care Management (CCM) and PCM categories as well as increased reimbursements for existing codes. In principle care management, the focus is on a single condition rather than two or more.
CPT Codes for Principal Care Management
CPT codes 99424, 99425, 99426, and 99427 will be accepted by Medicare in 2022, and HCPCS codes G2064 and G2065 will be discontinued.
The following elements must be included in CPT 99424: Chief care management services for a single high-risk disease:
- The patient has one chronic condition expected to last at least three months, and that poses a risk to him or her
- Significant risks include hospitalizations, acute exacerbations and decompensations, functional decline, and death
- Disease-specific care plans are required, medications need to be adjusted frequently, and comorbidities complicate the condition’s management,
- Care coordination and communication between relevant practitioners.
99424:Each calendar month, a physician or other qualified health care professional provides the first 30 minutes. In 2022, CPT 99424 will be reimbursed at an $81 rate.
99425:The reimbursement rate for CPT 99424 + 99425 in 2022 is $139 for each additional 30 minutes provided by a physician or other qualified health care professional in a calendar month.
99426:For one practitioner providing care, CPT 99426 describes principal care management services. Physicians or other qualified health care professionals direct the first 30 minutes of clinical staff time per calendar month. The reimbursement rate for CPT 99426 in the year 2022 is $61.
99427:Every 30 minutes of additional clinical staff time directed by a physician or qualified health care professional per calendar month (List separately from the primary procedure).CPT 99426 + 99427 reimbursement rate in 2022 is $108. Read more.
Frequently Asked Question about Principal Care Management
What are principal care management services?
A similar concept to Chronic Care Management (CCM) is Principal Care Management (PCM).In both programs, chronic illnesses can be addressed, but PCM focuses only on treating a single problem. If your patient is eligible for PCM, the diagnosis must last for three months to a year or be lifelong.
What is principal care management CMS?
The principal care management (PCM) model is a relatively new method to reimburse providers for treating chronic conditions.
Can 99454 and 99457 be billed together?
Medicare will issue additional guidance regarding remote patient monitoring under 99454. It is not possible to bill CPT codes 99457 and 99091 for the same billing period or beneficiary at the same time
Who can bill for principal care management?
Physicians and specialists can now bill PCM codes for services provided to patients with one serious chronic condition by a specialist or primary care physician. With PCM, a practitioner cannot bill for care management services for the same patient at the same time as another service.
Can CCM and PCM be billed together?
It is not possible to bill for PCM services and CCM services at the same time.PCM services may be provided by more than one clinician as long as each clinician treats different conditions.