One of the newest models of care reimbursed by the Centers for Medicare & Medicaid Services (CMS), principal care management (PCM) was first put in place in 2020. But it was completely overhauled in 2022, with four new principal care management CPT® Codes replacing the two earlier PCM codes. Here’s a closer look at those new principal care management CPT codes, and the reimbursement amounts available to billing practitioners.
> New to principal care management? Get a crash course on PCM here.
How we got here: PCM codes from 2020-2021
From 2020 through the end of 2021, CMS offered reimbursement for the treatment of chronic conditions with PCM services through two HCPCS codes:
- HCPCS code G2064 offered reimbursement for at least 30 minutes of physician time, or time from another qualified health care professional (QHP) per calendar month.
- HCPCS code G2065 offered reimbursement for at least 30 minutes of clinical staff time (such as that provided by nursing professionals) as directed by a physician or QHP.
For these original PCM codes, principal care management was defined by CMS (via the AACP) as “comprehensive care management for a single high-risk disease service.” The following was required for patients to qualify for reimbursable PCM services:
- One “complex chronic condition lasting at least 3 months, which is the focus of the care plan”
- A condition that’s “of sufficient severity” to put the patient “at risk of hospitalization or have been the cause of a recent hospitalization”
- A condition that requires the “development or revision” of a disease-specific care plan
- A condition that requires “frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities”
An abbreviation of Healthcare Common Procedure Coding System, HCPCS codes are offered by CMS to provide cost reimbursement for services or products that haven’t yet been included in the CPT® (Current Procedural Terminology®) Codes. HCPCS codes always begin with a letter, while CPT Codes always begin with a number. CPT Code is also a registered trademark of the American Medical Association (AMA).
CPT 99427, 99426, 99425 & 99424: A closer look at the new principal care management CPT Codes for 2022
As of January 1, 2022, the two earlier PCM codes described above have been replaced by four new CPT Codes. The guidelines are almost identical to that of the earlier HCPCS codes, establishing that patients must have a single high-risk disease to qualify. Specifically, to be a beneficiary of PCM care, the qualifying patient must have:
- One “complex chronic condition” that’s “expected to last at least 3 months,” and that places the patient at significant risk of death, hospitalization, acute exacerbation/ decompensation, or functional decline
- A condition that requires the active, specialized “development, monitoring, or revision of disease-specific care plan”
- A condition that requires “frequent adjustments in the medication regimen,” and/or management that’s “unusually complex due to comorbidities”
- Ongoing communication and care coordination “between relevant practitioners furnishing care,”, which can be carried out via telehealth or virtual/remote devices
So, what’s a “single high-risk disease”? In this context, the single condition equals a chronic condition. (Remember, the principal difference between PCM and chronic care management (CCM) is that CCM requires 2 chronic conditions, while PCM requires just one. PCM is also designed in part to help ensure that a patient doesn’t acquire another chronic condition (a.k.a., a comorbidity) while dealing with the initial disease.
Chronic conditions are lifelong diseases that include heart disease, diabetes, cancer, asthma, arthritis, chronic obstructive pulmonary disease (COPD), Alzheimer’s disease, Crohn’s disease, hepatitis and quite a few others. You can find a more comprehensive list of chronic conditions here.
CPT 99424
What is CPT Code 99424?
CPT Code 99424 covers the initial 30 minutes of time per calendar month of PCM services, including the creation of a disease-specific care plan by a physician or QHP. This usually involves the creation of the initial care plan by the primary care provider or chronic care specialist. (Along with 99425, 99424 is basically an expansion of what was earlier available under G2064.)
Who’s the billing practitioner?
Eligible billing practitioners for CPT Code 99424 are physicians or QHPs (usually advanced practitioners like physician assistants or nurse practitioners).
What’s the reimbursement for CPT 99424?
As of January 1, 2022, the reimbursement for CPT 99424 is $83.40 per 30 minutes of time, per patient per month (PPPM).
CPT 99425
What is CPT Code 99425?
CPT Code 99425, which covers each additional 30 minutes of time per calendar month, as carried out by a physician or QHP. This often involves the ongoing revisions that aren’t just associated with primary care management, but built into the process, such as active management of a patient’s medication regimen.
Who’s the billing practitioner?
Eligible billing practitioners for CPT Code 99425 are physicians or QHPs (usually advanced practitioners like PAs or NPs).
What’s the reimbursement for CPT 99425?
As of January 1, 2022, the reimbursement for CPT 99425 is $60.22 per 30 minutes of time, PPPM.
CPT 99426
What is CPT Code 99426?
CPT Code 99426, which covers the first 30 minutes of PCM clinical staff time, as carried out by clinical staff (such as nursing professionals) under the direction and guidance of a physician or QHP. Along with 99427, 99426 is basically an expansion of what was earlier available under G2064.
Who’s the billing practitioner?
Eligible billing practitioners for CPT Code 99426 are clinical staff such as nursing professionals, working under the specific guidance of a physician or QHP (usually an advanced practitioner, like a PA or NP).
What’s the reimbursement for CPT 99426?
As of January 1, 2022, the reimbursement for CPT 99426 is $63.33 per 30 minutes of time, PPPM.
CPT 99427
What is CPT Code 99427?
CPT Code 99427, which covers each additional 30 minutes of PCM clinical staff time, as carried out by clinical staff (such as nursing professionals) under the direction and guidance of a physician or QHP.
Who’s the billing practitioner?
Eligible billing practitioners for CPT 99427 are clinical staff such as nursing professionals, working under the specific guidance of a physician or QHP (usually an advanced practitioner, like a PA or NP).
What’s the reimbursement for CPT 99427?
As of January 1, 2022, the reimbursement for CPT 99427 is $48.45 per 30 minutes of time, PPPM.
Looking for more context on PCM codes?
See how PCM codes compare to transitional care management (TRM), remote patient monitoring (RPM), chronic care management services (CCM) and other models of telehealth with our handy Reimbursement Tree.
And if your organization is looking for ways to leverage PCM services or other telehealth technology for patient care, we may be able to help! Contact us now to connect to a CareSimple specialist.