Medicare’s 2020 final rule includes several updates to payment policies, coding, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). Keeping up with yearly CMS updates can be challenging and many providers rely on medical billing companies to submit claims and get reimbursed for services described by new and revised codes. In CY 2020, there is one significant update for care management of patients with complex health care needs. CMS has introduced two codes in a new category of reimbursement titled “Principal Care Management” (PCM) Services. These codes are meant to be billed by a specialist managing a patient with a single, complex, or high-risk condition.

New PCM codes for managing 1 serious chronic condition

The Chronic Care Management (CCM) CPT codes that CMS introduced in 2015 require that a patient have a diagnosis of at least two chronic conditions in order to bill Medicare for care management services. CMS came up with concept of Principal Care Management services to fill a gap left by the CCM codes, that is, provision of care management services for patients with a single high-risk disease or complex condition. The two new codes for PCM services are HCPCS G2064 and HCPCS G2065:

  • HCPCS G2064: Comprehensive care management services for a single high-risk disease, e.g. Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements:
    • One complex chronic condition lasting at least 3 months, which is the focus of the care plan;
    • The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization;
    • The condition requires development or revision of disease-specific care plan;
    • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.
  • HCPCS G2065: Comprehensive care management for a single high-risk disease services [sic], e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements:
    • One complex chronic condition lasting at least 3 months, which is the focus of the care plan;
    • The condition is of sufficient severity to place a patient at risk of hospitalization or have been cause [sic] of a recent hospitalization;
    • The condition requires development or revision of a disease-specific care plan;
    • The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

Key requirements for billing PCM services

  • Both codes can be billed only a physician or other qualified health care practitioner (QHCP).CMS expects the PCM codes to be used by specialties, including infectious disease, rheumatology, and pulmonology (www.medscape.com).
  • The Final Rule states that PCM services will typically be triggered by exacerbation of a qualifying condition that calls for disease-specific care (management by a specialized practitioner).
  • PCM services are those provided to a patient with one serious chronic condition which is typically expected to last between 3 months and a year, or until the death of the patient.
  • The code description states that the condition may have led to a recent hospitalization and/or will place the patient at significant risk for death, acute exacerbation/decompensation, or functional decline.
  • The Final Rule states that the expected outcome of the provision of PCM services is for the patient’s condition to be stabilized by the treating specialist clinician so that overall care can be returned to the patient’s primary care physician.
  • The new PCM codes are time-based and require the development of a disease-specific care plan, informed verbal consent, and documentation of the services provided by:
    • the physician, nurse practitioner, or physician assistant, for G2064
    • clinical staff, for G2065
  • The physician may bill PCM simultaneously with Remote Physiologic Monitoring (RPM), but may not bill PCM with other care management codes (such as CCM) for the same patient/month.
  • While billing Chronic Care Management (CCM) codes requires a comprehensive care plan, billing PCM codes requires the practitioner to develop a disease-specific care plan.
  • PCM requires that communication/care coordination between all practitioners furnishing care to the beneficiary be documented by the practitioner billing for PCM in the patient’s medical record.
  • HCPCS code G2065 allows for PCM services to be provided by clinical staff incident-to the billing physician or QHCP. The services must be provided under General Supervision, which means that the billing practitioner must be available to answer the clinical staff member’s questions and intervene when necessary, though they need not be co-located in the same office as the clinical staff member providing the services.
  • To initiate PCM services, the billing practitioner has to conduct an initial face-to-face visit (this can be an annual wellness visit (AWV) or other separately billable visit). At the initiating visit, the practitioner should educate the patient on PCM, obtain the patient’s verbal or written consent, and develop a comprehensive care plan in the electronic health record (EHR).

Accurate documentation and coding are indispensable for proper patient care as well as for getting reimbursed for services provided. Practitioners looking for help to bill CCM services using the new codes can get the support they need from an experienced physician billing company.