Understanding the 2023 Principal Care Management Code Updates

The Center for Medicare and Medicade Services (CMS) released new codes for principal care management 2022 on November 2, 2021. The new codes are designed to provide additional care management services for patients with a single chronic condition. PCM can be seen as an extension of traditional primary care services, and these new codes will allow providers to bill for their work in this area.

The new PCM codes were released because of a recent RVS update committee (RUC) survey that indicated that the majority of primary care collaboration services are undervalued. As per the survey results, the RUC recommended the changes that CMS has officially embraced.

The four new PCM codes will replace the previous HCPCS codes G2064, G2065. The codes will be an additional reimbursement opportunity to primary care physicians for their work to care for high-risk patients, e.g., allergists treating severe asthma patients that meet the criteria will be paid monthly on top of the existing E/M codes. 

 

Revised principal care management codes and reimbursement:

From January 1, 2022 Medicare is accepting principal care management codes 99424, 99425, 99426 and 99427. These codes are to report the physician's or other qualified healthcare professional's (QHP) personal time managing a patient's care.

Code 99424:  Principal care management service for the first 30 minutes provided personally by a physician or other qualified healthcare professional per calendar month for a single high-risk condition with the following elements:  

• One high-risk chronic condition is 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 needs development, monitoring, or revision of a care plan specific to a disease.

• The condition requires frequent adjustments in the medication regime and/or the management of the disease is unusually complex due to comorbidities, ongoing communication, and care coordination between relevant practitioners giving the care.

Note: The above elements apply to all new PCM medical codes.

Code 99425: PCM service for a single high-risk disease for each additional 30 minutes provided personally by a physician or other qualified healthcare professional, per calendar per month (list separately in addition to code for primary procedure).

Code 99426: Principal care management services for a single high-risk condition for the first 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional per calendar month.

Code 99427: PCM services, for a single high-risk disease, for each additional 30 minutes of clinical staff time directed by the physician or other qualified healthcare professional per calendar month.

The code numbers above represent specific services that offer care management for high-risk conditions. The table below shows the billable time of the principal management codes and their reimbursements.

 

 

How does PCM billing differ from CCM billing?

PCM and CCM are both care management services, but they differ in how they are structured and delivered. The need for PCM arose from the RUC's finding that primary care physicians were not reimbursed fairly for the care management services they provided. Chronic care management billing differs from PCM billing in a few key ways.

• First, CCM codes are reported on a per-member, per-month basis, while PCM codes are reported on a per-calendar-month basis.

• In addition, CCM codes require that the care plan be reviewed and updated at least once every 60 days, while there is no such requirement for PCM codes.

• Finally, CCM codes require 20 minutes of clinical staff time per month, while PCM codes only require 30 minutes of clinical staff time per month.

By understanding the differences between these two types of care management services, you can ensure that you correctly bill for the services you provide. In addition, you can avoid any errors that could result in reimbursement issues.

 

Billing for new PCM services:

You will report principal care management 2022 codes the same way you report chronic care management codes. The only difference is that you will use the new PCM codes when billing for services starting January 1, 2022. As with all care management codes, you must document the time you spend providing PCM services. In addition, you will need to document the patient's risk factors and your care plan. You can take the following steps when billing for PCM services.

• To bill for new PCM codes, document the time you spend providing PCM services, the patient's risk factors, and your care plan.

• Then, when billing for PCM services, use the new PCM codes (99424-99427) and remember to send invoices to patients receiving PCM services once per month and include a detailed description of the services provided.

• You will be reimbursed for PCM services the same way you would be reimbursed for any other care management service.

 

Required documentation when billing for new PCM codes

As with all care management codes, documentation should be specific and detailed. Be sure to include the date of service, as well as the start and end times for each service you provide. In addition, you will need to have the following information in your documentation:

• The patient's diagnoses or problems that led to the need for PCM services 

• The patient's risk factors (for example, age, BMI, comorbidities)

• Your care plan for the patient.

• The services you provided, and the time you spent providing each service

• The outcome of your services (for example, improved blood pressure, weight loss, etc.).

• The names and contact information of any other providers you coordinate care with.

 

The new codes for principal care management 2022 are a positive step forward for care coordination, and they will help to compensate physicians for the time they spend coordinating care for their patients. In addition, the new codes will encourage physicians to provide care management services to more patients. It is expected that the use of PCM codes will continue to increase in the coming years.

As the use of new care coordination, CPT codes 2022 increases, it is crucial that physicians document their services carefully. This will help ensure they are compensated adequately for their time and efforts. In addition, careful documentation will help to improve the quality of care coordination services. HMS USA LLC Medical Billing Company in NY has the knowledge and experience to help you improve your primary care coordination services. We can provide you with the resources and support you need to ensure that you are correctly billing for your services.