Principal Care Management (PCM) is a Medicare Part B service that provides reimbursement for the management of patients with a single, complex chronic condition. Where CCM requires two or more chronic conditions, PCM fills a gap for patients whose care is dominated by one high-risk diagnosis.
PCM was introduced in 2020 using HCPCS G-codes (G2064 and G2065). In the CY 2022 Physician Fee Schedule final rule, CMS replaced these G-codes with four CPT codes: 99424, 99425, 99426, and 99427.
Patient Eligibility:
The qualifying condition must be expected to last at least three months and must place the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death. The condition must require development, monitoring, or revision of a disease-specific care plan. In many cases, the management of the condition is unusually complex due to comorbidities, or requires frequent adjustments in the medication regimen.
Common scenarios include a patient with advanced heart failure seen by a cardiologist, a patient with complex diabetes managed by an endocrinologist, or a patient with chronic kidney disease under the care of a nephrologist. PCM is well suited to specialty practices that focus care management on a single dominant condition.
CPT 99424: First 30 minutes of PCM provided personally by a physician or qualified health care professional (QHP), per calendar month.
CPT 99425: Each additional 30 minutes of PCM provided personally by a physician or QHP, per calendar month. Add-on to 99424.
CPT 99426: First 30 minutes of PCM provided by clinical staff under the direction of a physician or QHP, per calendar month.
CPT 99427: Each additional 30 minutes of clinical staff time for PCM, per calendar month. Add-on to 99426.
Key Distinctions from CCM:
PCM requires a disease-specific care plan focused on the single qualifying condition, rather than the comprehensive care plan required for CCM. A systematic needs assessment and receipt of preventive services are only required if they apply to the condition being treated. PCM and CCM cannot be billed for the same patient in the same calendar month.
Sources:
CMS CY 2020 and CY 2022 Physician Fee Schedule final rules;
CodingIntel PCM overview; AAFP coding guidance.
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