The Centers for Medicare and Medicaid Services (CMS) has enormous influence in the field of medical billing. That isn’t surprising, given the importance of Medicare and Medicaid billings to physician revenue. When CMS decrees that it will only pay bills that meet a specified standard, physicians quickly adopt that standard.
In 2020, CMS adopted a program that it called principal care management (PCM). The program’s underlying premise is that primary care physicians typically manage the overall care of their patients, while specialists typically manage specific chronic health conditions (such as cancer treatment).
When specialists manage a single chronic health condition, it may be more efficient and less costly for them to follow patients and manage their care without requiring each contact between physician and patient, or staff and patient, to be conducted face to face. The PCM program allows physicians who manage a single chronic condition to be reimbursed for those remote services.
After monitoring the PCM program for two years, the CMS determined that the program is valuable but underutilized. In an effort to give physicians a greater incentive to implement a PCM program, the CMS adopted four new CPT billing codes in 2022. Those codes give physicians more opportunity to bill for PCM services.
What Is Principal Care Management?
The CMS intended PCM to improve the care of patients who suffer from chronic health conditions. Examples of chronic diseases include cancer, heart disease, stroke, diabetes, and Alzheimer’s.
Before it created PCM, the CMS-approved billing Medicare or Medicaid for care coordination services provided outside of regular office visits for patients who had more than one chronic condition. That program, known as Chronic Care Management (CCM), allowed medical practices to bill for clinical staff time that is devoted to treating the patient outside of face-to-face contact with a healthcare provider. The staff member who provides the remote treatment must act under the direction of a physician or qualified health care professional. Sessions must last at least 20 minutes to be billable.
The CCM program is limited to patients who have two or more chronic health conditions. The PCM program is similar to CCM but covers reimbursement for out-of-office services provided to patients who have only one chronic health condition. It also overs reimbursement for out-of-office treatment of only a single chronic health condition in patients who suffer from multiple chronic health conditions. One difference between the programs is that PCM only reimburses out-of-office services that last 30 minutes or more.
The goal of both PCM and CCM is to stabilize chronic conditions more quickly so that patients can return to their primary care physician for management of their overall care. Health care costs are generally reduced when health care can be managed by a primary care physician rather than a specialist.
From the patient’s perspective, having regular sessions with physicians and staff members outside of office visits is convenient and reassuring. Patients report that they feel safe and more valued when they are in regular contact with medical staff.
CPT Codes for PCM
Uniform billing systems make it possible for private insurers and CMS to understand exactly what service the provider delivered. To that end, American Medical Association created and maintains thousands of codes — known as Current Procedural Terminology (CPT) codes — that describe each service or procedure for which a healthcare provider might bill. The CMS incorporated CPT codes into its own coding system, the Healthcare Common Procedure Coding System (HCPCS).
In 2020, CMS approved two new CPT codes to support PCM. One code was approved to describe at least 30 minutes of physician provider time with a patient. The other was used to describe at least 30 minutes of staff provider time.
To use the codes, the practice was required to provide comprehensive case management services to a patient who has a qualifying chronic health condition. A qualifying complex chronic condition must be expected to last at least 3 months and must place the patient at risk of hospitalization unless it already caused the patient’s hospitalization.
The qualifying condition must require and be the focus of a disease-specific case management plan. The condition must either require frequent adjustment of a medication regimen or must require unusually complex management because of comorbidities.
The billing code for clinical staff time may be used only when the staff member’s time is directed by a physician or other qualified healthcare professionals. The CMS did not allow both the physician CPT code and the staff CPT code to be billed in the same month.
Changes to CPT Codes in 2022
With two years of experience, the CMS determined that PCM services were undervalued. It raised the authorized reimbursement rates in 2022. It also scrapped the two CPT codes that it implemented in 2020. It replaced those codes with four codes that closely track the codes used for CCM billing.
The new PCM codes apply to patients who have a single high-risk disease or complex chronic condition. The codes apply to the following services:
- CPT code 99424 describes the first 30 minutes of PCM services for a single high-risk disease provided personally by a physician or other qualified health care professional within a calendar month.
- CPT code 99425 describes each additional 30 minutes of PCM services for a single high-risk disease provided personally by a physician or other qualified health care professional within a calendar month.
- CPT code 99426 describes the first 30 minutes of PCM services for a single high-risk disease provided by clinical staff when directed by physician or other qualified health care professional within a calendar month.
- CPT code 99427 describes each additional 30 minutes of PCM services for a single high-risk disease provided by clinical staff when directed by physician or other qualified health care professional within a calendar month.
As the codes apply on a monthly basis, the 99424 and 99426 codes may only be billed once per month. Each additional 30-minute increment of services during that month must be billed using the 99425 or 99427 codes, depending on whether services were provided by the physician or staff.