The Principal Care Management (PCM) service was created by the Centers for Medicare and Medicaid Services (CMS) in 2020. The aim of the program was to allow for provision of additional care to patients with a single chronic condition. In 2022, there are four new codes to bill PCM services that replace two existing codes for these services. When introducing PCM services, CMS expected that specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management will bill PCM services the most. Outsourcing medical billing is an ideal option to meet the requirements for billing PCM codes.

Principal Care Management Services: Key Points

CMS defines a typical patient (for PCM) as one that “may present to their primary care practitioner with an exacerbation of an existing chronic condition.” With the PCM codes, practices can bill for care management for services provided to patients with one serious chronic condition by a specialist or primary care physician. While Chronic Care Management Services (CCM) focus on the care of two or more chronic conditions, PCM describes care management services for a single, complex chronic condition. The key elements for the provision of PCM services are as follows:

  • A qualifying condition for PCM services may be expected to last between three months to one year or until the death of the patient.
  • The qualifying condition should be of such complexity that it cannot be managed effectively by primary care and requires management by another, more specialized practitioner.
  • Typically, a PCM service is initiated to address an exacerbation of the patient’s chronic condition or recent hospitalization.
  • While a specialist may manage services for the specific chronic condition, the patient’s primary care physician will continue to supervise the patient’s overall care.
  • A patient can receive PCM services from multiple specialists for multiple different conditions simultaneously, for e.g., a cardiologist for arrhythmia and a pulmonologist for chronic obstructive pulmonary disease (COPD).

New PCM Codes for 2022

In 2022, four new PCM codes replace the two previous PCM codes (HCPCS codes G2064 and G2065):

  • CPT code 99424: PCM services for a single high-risk disease first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month
  • CPT code 99425: PCM services for a single high-risk disease each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month
  • CPT code 99426: PCM, for a single high-risk disease first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month
  • CPT code 99427: PCM services, for a single high-risk disease each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

Requirements for Billing PCM Services

CMS has set forth several requirements that must be met for billing PCM codes for services provided to a patient. Important conditions include:

  • The billing practitioner must be a physician or a qualified health care practitioner.
  • PCM services should not be reported by the same practitioner simultaneously with other care management services.
  • According to the Final Rule, the expected outcome of the provision of PCM services is for the patient’s condition to be stabilized by the treating specialist so that overall care can be returned to the patient’s primary care practitioner.
  • The billing practitioner should document ongoing communication and care coordination between all practitioners providing care to the patient.
  • For new patients and patients not seen within a year prior to initiation of PCM, the billing practitioner must conduct an initiating visit with the patient to educate the patient on PCM and obtain the patient’s informed consent. This visit can be an annual wellness visit (AWV) or other separately billable visit.
  • Consent – The patient’s informed consent can be obtained verbally or in writing and should be documented in the patient’s medical record.

PCM services are aimed at improving patient health outcomes, but not reporting PCM services correctly can leave revenue on the table. Outsourced medical billing and coding services can help primary care physicians and specialists treating high-risk diseases or complex chronic conditions to get properly reimbursed for the services they provide.