In the Final Medicare Physician Fee Schedule (MPFS) for 2022 issued on November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) added five new CPT codes in the categories of Chronic Care Management (CCM) and Principal Care Management (PCM) and increased reimbursement for already existing codes in the same categories. These codes are like chronic care management services in that the work involves the establishment, implementation, revision, and monitoring of a care plan for a patient. However, principal care management focuses on a single condition (rather than two or more). In the year 2022, Medicare will accept CPT codes 99424, 99425, 99426, and 99427, and discontinue HCPCS codes G2064 and G2065.
2022 Revised Codes for Principal Care Management
CPT 99424: Principal care management services, for a single high-risk disease, with the following, required elements:
- one complex chronic condition expected to last at least 3 months, and that places the patient at
- significant risk of hospitalization, acute exacerbation/ decompensation, functional decline, or death,
- the condition requires development, monitoring, or revision of a disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities,
- ongoing communication and care coordination between relevant practitioners furnishing care.
The first 30 minutes are provided personally by a physician or other qualified health care professional, per calendar month. The reimbursement rate for CPT 99424 in the year 2022 is $81.
CPT 99425: For each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure. The reimbursement rate for CPT 99424 + 99425 in the year 2022 is $139.
CPT 99426: Principal care management services, for a single……. between relevant practitioners furnishing care. The first 30 minutes of clinical staff time are directed by the physician or other qualified health care professional, per calendar month. The reimbursement rate for CPT 99426 in the year 2022 is $61.
CPT 99427: For each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month (List separately in addition to code for primary procedure. The reimbursement rate for CPT 99426 + 99427 in the year 2022 is $108.
PCM Vs CCM
Principal care management (PCM) works much like chronic care management (CCM). Both programs help address chronic illness, but PCM is focused on treating only one, sole issue. To qualify for PCM, the patient must have a diagnosis that is expected to last between three months to a year or is life-long. The condition must be associated with recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation or decompensation, or in a state of functional decline. For your patient to participate in PCM, they must provide written or verbal consent, which in turn must be documented by your practice. Another key difference between PCM and CCM is the time required for billing. While CCM has a 20-minute requirement, PCM has a 30-minute requirement before it can be billed.
About MedicalBillersandCoders
For a detailed understanding of billing for Chronic Care Management Services, you can refer MLN document. Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We can assist you in receiving accurate insurance reimbursements for Chronic Care Management (CCM) and Principal Care Management (PCM). To learn more about our medical billing and coding services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
FAQs on Principal Care Management (PCM) and Chronic Care Management (CCM) Billing Codes for 2022
1. What are the new CPT codes introduced for Principal Care Management (PCM) in 2022?
In 2022, Medicare introduced new CPT codes for Principal Care Management (PCM): 99424, 99425, 99426, and 99427. These codes replaced HCPCS codes G2064 and G2065 and focus on managing a single high-risk chronic condition that requires ongoing monitoring and care coordination.
2. How does Principal Care Management (PCM) differ from Chronic Care Management (CCM)?
While both PCM and CCM address chronic illnesses, PCM is specific to managing a single high-risk condition, whereas CCM involves managing two or more chronic conditions. PCM requires a 30-minute time threshold for billing, compared to CCM’s 20-minute requirement.
3. What is the reimbursement rate for CPT 99424 and 99425 for Principal Care Management in 2022?
In 2022, CPT code 99424 (for the first 30 minutes of care provided personally by a physician or qualified healthcare professional) is reimbursed at $81. For each additional 30 minutes (CPT 99425), the reimbursement rate is $58, making the total $139 for 99424 + 99425.
4. What are the requirements to bill CPT 99426 and 99427 for PCM services provided by clinical staff?
CPT 99426 covers the first 30 minutes of PCM services provided by clinical staff under the direction of a physician, with a reimbursement rate of $61 in 2022. CPT 99427 covers each additional 30 minutes and is reimbursed at $47, totaling $108 for 99426 + 99427.
5. What are the patient qualifications to enroll in Principal Care Management (PCM) services?
To qualify for PCM, a patient must have a high-risk condition expected to last at least 3 months and place the patient at significant risk of hospitalization, exacerbation, or functional decline. The patient must provide verbal or written consent, which must be documented by the practice.
