Principal Care Management Billing Codes for FY 2022

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. Under the new PCM codes, specialists may now be reimbursed for providing their patients with care management services that are more targeted within their own particular area of specialty.

 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

Earlier HCPCS Codes (Comprehensive Care Management Services):

HCPCS Code 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 Code G2065

Comprehensive care management for a single high-risk disease services, 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 patient at risk of hospitalization or have been 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

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.
• The billing practitioner should document ongoing communication and care coordination between all practitioners providing care to the patient.
• 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.
• Consent – The patient’s informed consent can be obtained verbally or in writing and should be documented in the patient’s medical record.
• 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.