EM Coding Alert

Question: Who can provide principal care management (PCM) services, and what activities will count in calculating time for them?

Kentucky Subscriber

Answer: CPT^® provides two codes for PCM services performed personally by a physician or other qualified healthcare professional (QHP) and two codes for PCM services performed by clinical staff directed by a physician or other QHP.

Physicians and other QHPs would report services they personally perform using 99424 (Principal care management services … first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month) and +99425 (… additional 30 minutes …).

Clinical staff, such as medical assistants (MAs), licensed practical nurses (LPNs), registered nurses (RNs), and others depending on the scope of practice as defined by state law under the direction of a physician or other QHP, may provide the services you report using 99426 (Principal care management services … first 30 minutes of clinical staff time …) and +99427 (… each additional 30 minutes …).

Remember, too, that “if the treating physician or other qualified health care professional personally performs any of the care management services and those activities are not used to meet the criteria for a separately reported code (99424, 99491), then his or her time may be counted toward the required clinical staff time to meet the elements of 99426, 99487, 99490 as applicable,” according to the American Medical Association (AMA) CPT^® Professional 2022. So, be sure to capture all clinical care management minutes, as they may be reportable regardless of whether the clinician meets the minimum threshold for a given month.

Also, remember that PCM is for a patient with a single complex chronic condition that is expected to last at least three months. The condition must also place the patient at significant risk of hospitalization. PCM services also must follow the requirements outlined in CPT^®, including around-the-clock patient access to physicians or QHPs, use of an electronic medical record (EMR), as well as a dedicated care team member who ensures continuity of care.

Activities that you can count toward PCM codes include developing, monitoring, or revising a disease-specific care plan. CPT^® describes “adjustments in the medication regimen and/or the management of the condition,” and “ongoing communication and care coordination between relevant practitioners furnishing care.” Essentially, all things that contribute to the care plan can be counted.