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Principal Care Management (PCM) Codes for 2024

Updated: Apr 28

Medicare Part B patients encounter minimal co-pays for PCM and can benefit from tailored care plans and assistance in cultivating self-management practices through the PCM program.

 

Introduction To New PCM CPT Codes

Within the Principal Care Management category of the Medicare Physician Fee Schedule (MPFS), the Centers for Medicare & Medicaid Services (CMS) have replaced the former PCM codes (HCPCS codes G2064 and G2065) with four new CPT codes.


PCM aims to reimburse physicians for the additional efforts they put into caring for high-risk complex chronically ill patients, including medication adjustments, devising comprehensive care plans, patient follow-up, and more. CMS strives to enhance care coordination for PCM patients, even if it entails paying physicians more, with the goal of keeping them out of the hospital.

 

What Is CPT Code 99424?

This code encompasses the initial 30 minutes of PCM services per calendar month, including a physician's or qualified healthcare professional's formulation of a disease-specific care and treatment plan. CPT code 99424 extends the services previously provided under G2064.


Physicians, qualified healthcare professionals, advanced practitioners, physician assistants, and nurse practitioners are eligible to bill under CPT Code 99424. The average reimbursement rate for CPT 99424 is $83.40 per patient per month for every 30 minutes of time (reimbursement amount varies by location).

 

What Is CPT Code 99425?

CPT code 99425 applies to each additional thirty minutes that a physician or qualified healthcare professional devotes throughout a calendar month. This typically involves ongoing adjustments not only related to primary care management but also integral to proactive medication management for patients.


Medical professionals, qualified healthcare professionals, advanced practitioners, physician assistants, or nurse practitioners may bill under CPT Code 99425. The average payment for this code is $60.22 per 30 minutes of time (amount varies by location).

 

What Is CPT Code 99426?

The initial 30 minutes of PCM clinical staff time, conducted by clinical staff under the supervision and guidance of a physician or qualified healthcare professional, is covered by CPT Code 99426. It expands upon what was previously available under G2064 alongside 99427.


Clinical professionals and nurses employed under the specific supervision of a doctor or qualified healthcare professional, such as a physician assistant or nurse practitioner, are eligible billing practitioners for CPT Code 99426. The average reimbursement for CPT 99426 is $63.33 per 30 minutes of time (amount varies by location).

 

What is CPT Code 99427?

Each additional 30 minutes of PCM clinical staff time, performed by clinical staff and nurses under the supervision and guidance of a physician or qualified healthcare professional, is covered under CPT Code 99427.


Clinical professionals, nurses, qualified healthcare professionals (QHPs), advanced practitioners, physician assistants, or nurse practitioners are eligible billing practitioners for CPT 99427. The reimbursement rate for this code is $48.45 for 30 minutes of time (amount varies by location).

 

All About the Billing Requirements for PCM CPT Codes

Between routine visits, PCM enables providers to engage with patients once a month. Deliverable remotely via phone or telehealth platform, it is billable when the patient spends at least 30 minutes completing necessary tasks. PCM services encompass:


• Monthly clinical evaluations

• Telephone calls

• Medical assessments

• Referrals to specialists

• Prescription refills

• Reviewing medical charts

• Scheduling services or appointments


To qualify for PCM billing, a patient must have one chronic illness, documented by the physician at least twelve months prior to enrollment. There must also be evidence of acute decompensation, significant risk of hospitalization, decline in bodily function, or risk of death. Medicare Part B covers 80% of PCM benefits for patients.

 

Who Can Provide Principal Care Management (PCM)?

An NPI-accredited provider must oversee the PCM billing process. Nevertheless, the majority of the program can be administered by qualified clinical administrators, saving doctors’ time and commitment. Other eligible providers include:

• Physicians

• Medical assistants

• Licensed nurse practitioners

• Certified midwives

• Clinical nurse specialists

• Pharmacists

 

Medicare Claims Submission for PCM Reimbursement

When submitting a Medicare claim, the following five items are required:

• CPT codes for each patient program overseen

• ICD-10 codes corresponding to each disease being managed in that program

• Date of service

• Service location (telehealth or in-office)

• National Provider Identifier (NPI) number


CPT codes 99424 and 99425 pertain to time spent by a physician or other licensed healthcare provider.


Clinical staff time under the supervision of a physician or other licensed healthcare provider is denoted by CPT codes 99426 and 99427.


Offer Chronic Care Management To Your Patients With ChronicCare


ChronicCare partners with Physicians, Hospitals, Payors, and Employers to offer Chronic Care Management Services to their patients. We are dedicated to helping people improve their health and quality of life by maximizing their healthcare outcomes. We bridge the gap between healthcare visits, in order to ensure patients are continually cared for each month. 


Click here to connect with our team, we'd love to discuss potential benefits to your patients, staff, and practice.


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