Principal care management (PCM) is a model of care for reimbursement of services provided to patients with one chronic condition. It is similar to the chronic care management (CCM) and transitional care models (TCM), with a bit of difference. In this article, we will provide a comprehensive guide to principal care management (PCM) and the rules providers need to follow when billing for PCM.
What is Principal Care Management?
Principal care management is a model of care for patients who have been living with one chronic condition for three months or more. According to the AACP:
“A patient would be eligible for PCM if they have a chronic condition that is expected to last at least three months. It would be a condition that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.”
In PCM, patients with chronic conditions require treatment for three months or more, and the need for PCM is judged necessary after a severe episode or hospitalization due to the condition. PCM services usually comprise care that quickly stabilizes the patient’s condition before transferring them to their primary care provider.
Usually, the provider or nurse develops a personalized care plan specific to the patient’s condition. The staff follows this care plan to provide healthcare services to the patient. This includes regular communication with the patient, monitoring and managing the patient’s condition and medicines, and other necessary tasks.
PCM Time Considerations
In 2022, CPT guidelines replaced two obsolete HCPCS Level II comprehensive care management services codes, G2064 and G2065, with three new PCM codes:
99424
Principal care management services for a high-risk disease with the following elements:
- One complex chronic condition that is anticipated to last at least three months puts the patient at a high risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.
- A condition that requires creating, monitoring, or revising a disease-specific care plan.
- The condition requires regular adjustments to the medication regimen and/or unusually complex management because of comorbidities.
- Continuing care coordination between providers: the first 30 minutes are administered by a physician or other qualified health care provider every month.
+ 99425
Additional 30 minutes provided by a physician or other qualified healthcare provider every calendar month (to be listed separately in addition to the code for the primary procedure).
99426
Primary care management for a single high-risk disease. Initial 30 minutes of clinical staff time directed by a physician or another qualified healthcare provider per calendar month.
+ 99427
Additional 30 minutes provided by a physician or other qualified healthcare provider every calendar month (to be listed separately in addition to the code for the primary procedure).
Note:
These codes cannot be billed if less than 30 minutes are documented and can only be billed every calendar month. A provider cannot bill for principal care management services and other care management services in the same calendar month
For the codes 99426 and +99427, a physician or qualified professional must supervise the services provided directly. Direct supervision can be defined by the Centers for Medicare and Medicaid Services (CMS) as the physician being immediately available for assistance. They do not have to be in the same room the entire time.
Additionally, you can include management and support services in the total time, such as development, implementation, altering, or monitoring the care plan, coordination of care, or any education required about the condition, care plan, or prognosis.
Clinical staff time can be used to fulfill the requirements of 99426 or +99427 or another management service, if the treating physician or another qualified healthcare professional provides PCM services that are not used as supportive criteria for 99424 or +99425.
The CPT® rules instruct us only to document the time of a single staff member or physician when more than one provider is tending to the same patient at the same time and not to include time spent doing other billable services.
Conclusion
Principal care management is set to become an integral part of the healthcare system in the coming years. With this care management system, providers can improve the engagement of patients in their own treatment and thus improve patient outcomes. It also opens a door for a new revenue stream for the billing practitioner.
With CareCloud’s principal care management services, providers can streamline principal care management workflows and increase practice revenue.
