What is PCM?

Principal Care Management (PCM) codes allow for the treatment of patients with a specific chronic condition and are associated with four CPT billing codes: 99424, 99425, 99426 and 99427. Osteoarthritis is included as a disease for these codes. The purpose of the codes for an orthopedic surgeon is to optimize pre-surgery planning.

In order to qualify, a patient must have:

• A diagnosis that is expected to last a minimum of 12 months or until end-of-life;
• A condition that places the patient at significant risk of death, acute exacerbation or decompensation, or in a state of functional decline, and/or is associated with a recent hospitalization;
• Written or verbal patient consent as documented by your practice, and it should be noted for 12 months prior to enrolling on the program.

The PCM program can lead to fewer hospital visits, and Medicare part B covers 80% of the patient cost. Each month, PCM is billable when at least 30 minutes are spent with the patient through support tasks like:

• Monthly clinical reviews
• Telephone calls
• Chart reviews
• Scheduling appointments/services
• Goal progress and motivation
• Prescription refills
• Referrals to providers
• Physician reviews

Note: Individual care plans should be created for, and in collaboration with, the patient during PCM enrolment.

Why implement PCM programs?

PCM programs can drive revenue and support cost savings. Not only that but they can be used to report data and meet specific value-based care quality metrics. PCM can engage patients thanks to its personalized nature, so you can establish goals or identify social determinants of health. This improves care coordination as well, and both patients and care managers benefit due to the monthly check ins.

Additionally, you can offer and bill PCM alongside Remote Patient Monitoring (RPM) and Behavioral Health Integration (BHI). However, RPM and BHI have their own billing codes and have their own service and time requirements that must be met separately from PCM.

PCM CPT codes and who can provide them

Those that can provide PCM include:

• Physicians and physician assistants
• Nurse practitioners
• Certified nurse midwives
• Clinical nurse specialists
• Pharmacists

The different CPT codes reflect the specific categories of PCM and whether you are a provider or a clinician, different codes will apply. Although there is little difference in the services delivered by a provider or clinician, it is good practice to use the most appropriate code depending on individual cases.

• 99424: 30 minutes per month (provider)‍
• 99425: 30 additional minutes per month (provider)‍
• 99426: 30 minutes per month (clinician)‍
• 99427: 30 additional minutes per month (clinician)

Note that providers cannot offer both PCM and Chronic Care Management (CCM) services to the same patient in any given month, but the patient may receive PCM services from one provider and CCM from another, as long as different conditions are being managed.

To bill for PCM, you should ensure CMS requirements are met for each patient each month, submit the claims to CMS monthly, send an invoice to patients receiving PCM services, and ensure no conflicting codes have been billed.

Finally, if you work for a Rural Health Clinic or Federally Qualified Health Center, you should utilize HCPCS code G0511 for general care management. It can be billed in multiple instances, including additional 30-minute increments of PCM and other programs, like RPM and BHI, so long as all relevant requirements are met for each program.

How can moveUP help?

The PCM codes require a comprehensive care plan of management of osteoarthritis. moveUP can provide this plan for the patient in the moveUP app and your team can monitor symptoms through the dashboard.

We make billing easy: in our PCM dashboard, the time periods are recorded automatically to ensure the monthly billing requirements are met. There is no need to document your time.

All notes can be added to the patient profile e.g. logging of a monthly call.

Want to learn more? Reach out to our team.

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