Basics of Principal Care Management (PCM)
In the Medicare Physician Fee Schedule final rule issued in November 2021, the Centers for Medicare and Medicaid Services (CMS) added four new CPT codes (99424, 99425, 99426, and 99427) in the category of Principal Care Management (PCM) to replace the two previous PCM codes (HCPCS codes G2064 and G2065). These new PCM codes are intended to reimburse physicians for the additional work they do caring for high risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up and more. CMS is trying to improve care for complicated PCM patients and keep them out of the hospital, and it is willing to pay physicians more to make that happen.
PCM Codes Description
CPT 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. (Medicare reimbursement rate for non-facility: $ 83.40)
CPT 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. (Medicare reimbursement rate for non-facility: $ 60.22)
CPT 99426
PCM services 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. (Medicare reimbursement rate for non-facility: $ 63.33)
CPT 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. (Medicare reimbursement rate for non-facility: $ 48.45)
Note that, CPT codes 99424 and 99425 are for time spent by a physician or other qualified health care professional. CPT codes 99426 and 99427 are for clinical staff time directed by a physician or other qualified health care professional. Keep in mind, provider/clinical staff time does not have to be face-to-face time. It can be time used to create care plans, follow-up with patients via phone, etc.
Coding updates for Principal Care Management (PCM) shared in this article address Medicare fee-for-service payment rules. For private insurances, you can refer reimbursement policy for verify coverage. Medisys Data Solutions is a leading medical billing company providing billing and coding services for various medical billing specialities. If you need any assistance in Medicare medical billing for your practice, contact us at info@medisysdata.com/ 302-261-9187
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Reference: What Is Principal Care Management? Elements and Benefits of Medicare’s Latest Program
