Principal Care Management: New Medicare CPT Codes

The goal of your medical practice’s presence in your community is to deliver great, high-quality care to your patients. Obviously, the type of care might be different from patient to patient, day-to-day. One kind of treatment is that of principal care management, also known as PCM. This entails caring for your patients who have one chronic condition, but PCM is different from chronic care management (CCM) and we’ll explore how later in this article.

There’s a special set of criteria for your medical practice to deliver PCM services and there are new medical billing codes for such services. Keep reading to learn more about principal care management and how it relates to Medicare, plus check out the new CPT codes for billing these services and general billing tips.

Quick Links:

• What Is Principal Care Management?
• New Medicare CPT Codes for PCM
• Best Practices for Medicare Billing

What Is Principal Care Management?

Principal care management is the category of medical care related to managing a single, complex chronic condition. For example, a patient dealing with the effects of long-term COVID would fall into this category of someone who needs principal care management.

PCM differs from CCM—chronic care management—because principal care only involves one chronic condition whereas CCM needs at least three chronic conditions to be present in order to bill for that service. The goal of principal care is to deliver a focused treatment and management plan to handle a patient’s chronic condition rather than balancing multiple chronic conditions simultaneously.

This terminology and this PCM category were developed by the Centers for Medicare and Medicaid Services in 2020 as a gap filler for patients who need focused care for one complex chronic condition but who don’t have multiple, coexisting conditions. Implementing these measures to address patients with chronic conditions benefits practices because 6 in 10 adults have a chronic condition.

Providing language and medical billing codes for this population of patients who don’t meet the qualifications for chronic care management services helps medical practices accurately bill for their time and services rendered. Streamlining the medical billing process with more accurate coding helps your overall healthcare revenue cycle and encourages more focused care for these patients with one chronic condition.

It’s important to note, however, that the types of care management services don’t have to be mutually exclusive. Medical practices that frequently see and treat patients covered by Medicare should consider billing for principal care management, chronic care management, and transitional care management (TCM) if applicable.

To accurately and appropriately bill for principal care management (PCM), patients must have one complex chronic condition that meets the following points of criteria:

• The condition is expected to last at least 3 months
• The condition puts the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death
• The condition requires the development, monitoring, or revision of a disease-specific care plan
• The condition requires frequent adjustments in medication treatments, and/or the management of the condition is complex due to comorbidities
• The condition requires ongoing communication and care coordination between relevant practitioners providing quality care
• The condition requires at least 30 minutes of PCM services rendered per calendar month

Ensure that your medical practice has the patient’s consent, the proper documentation to verify PCM care is needed, and bill with the appropriate codes for PCM services. 

New Medicare CPT Codes for PCM

The new Medicare CPT codes pertaining to principal care management coding and billing are as follows:

• 99424: Principal Care Management performed by a physician or non-physician provider for 30 minutes per calendar month (cost: $80.98)
• 99425: Additional 30 minutes per calendar month (cost: $58.46)
• 99426: PCM performed by clinical staff under the direction of a physician or other qualified healthcare professional for 30 minutes per calendar month (cost: $61.49)
• 99427: Additional 30 minutes per calendar month (cost: $47.04)

As with any part of the medical billing process, make sure to specify which type of principal care management was delivered to the patient so that your claims are accurate and appropriately reflect the level of care provided.

Best Practices for Medicare Billing

When it comes to the billing and coding process, be sure to follow these tips:

Be Careful of Accidentally Upcoding or Undercoding

Your medical practice should submit claims with the highest degree of accuracy and appropriate level of care provided. Developing a pattern of upcoding or undercoding can lead to audits, fines, or prosecution—and can lead to your practice being underpaid. Upcoding or undercoding can be the result of simply not keeping up with new coding regulations and can be entirely unintentional, so take the time to confirm your codes are accurate and appropriate.

Properly Submit Accurate Claims The First Time

Approximately 80% of medical bills contain inaccuracies, which leads to weeks of editing, resubmitting, and delaying payment for services rendered. Properly submitting your medical practice’s claims the first time ensures a smooth revenue cycle and enables your practice to move on to current claims instead of spending time reworking old ones. Be sure to double-check your claims before submitting them to Medicare so that you can avoid delaying your practice’s reimbursement!

Trust Your Medical Billing and Coding to the Experts at NCG!

Choosing the right medical billing company when outsourcing your billing processes is incredibly important for building and sustaining a successful healthcare practice. No matter your specialty or unique needs, having the right medical billing services can make all the difference when it comes to an efficient billing process and improved revenue cycle management. Additionally, it helps with following best practices to keep your practice in good standing with Medicare and Medicaid programs.

At NCG Medical, we’ve been the outsourced medical billing experts for four decades by handling all the ins and outs of the medical billing process. Our customized solutions can improve revenue management cycles and ensure that your practice is receiving the most streamlined reimbursement process.