General Surgery Coding Alert

See how CPT^® and CMS clear the way.

Changes to reporting E/M services didn’t stop in 2021. In fact, CPT^® 2022 presents multiple new codes for different types and levels of patient care that your surgeons may perform.

One of those services is principal care management (PCM), which involves handling patient care for one complex chronic condition. Read on to learn how coding and coverage is about to change for PCM.

Understand PCM

The key distinguishing feature of PCM is management of a single chronic condition. Although the primary care physician will continue to oversee the patient’s total care, a specialist may manage services for a specific chronic condition. By definition, the chronic condition would be expected to require management for three months or more, and the need for PCM would usually become apparent following a severe episode or hospitalization related to the condition.

Different: CPT^® provides codes for chronic care management (CCM), but those codes describe the healthcare practitioner’s focus on two or more chronic conditions. You’ll also see changes to CCM coding in 2022, and you can learn more about that in future issues of General Surgery Coding Alert.

In With The New Codes

CPT^® 2022 introduces the following four new codes for PCM, which will be effective Jan. 1, 2022:

• 99424 (Principal care management services, for a single high-risk disease, with the following required elements:

o 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,

o the condition requires development, monitoring, or revision of disease-specific care plan,

o the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities,

o ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month)

• +99425 (…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))
• 99426 (… first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)
• +99427 (…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))

“Codes 99424 and +99425 describe PCM services performed by a physician or other qualified healthcare professional, while 99426 and +99427 describe clinical staff time,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, billing specialty subject matter expert at Kareo in Irvine, Calif.

Don’t miss: Each of these codes represents 30 minutes of service time, but the unit of service is “per month.” That means you should report 99424 and/or 99426 only once per month. You should use the add-on codes for any additional 30-minute increments during the same month.

Know CMS’ Proposed Guidance

The Centers for Medicare and Medicaid Services (CMS) recent Medicare Physician Fee Schedule (MPFS) proposed rule addresses how practitioners should report PCM services for Medicare beneficiaries in 2022.

“Next year, Medicare is proposing to accept and pay for new CPT^® codes for Principal Care Management (PCM),” says Lori Carlin, CPC, COC, CPCO, CCS, Director, Professional Coding Services, Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

“A patient would be eligible for PCM if they have a chronic condition that is expected to last at least three months. It would be a condition which places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,” Carlin says.

Background: The proposed rule reminds that in the calendar year 2020 MPFS, CMS “created two new HCPCS G codes, G2064 and G2065, representing comprehensive services for a single high-risk disease (that is, principal care management).

If you’ve been reporting PCM services for Medicare beneficiaries, you should have been using one of these two codes:

• G2064 (Comprehensive care management services for a single high-risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospital­ization or have been the cause of a recent hospitalization, the condition requires development or revision of 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)
• G2065 (Comprehensive care management for a single high-risk disease services, e.g. principal care management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of 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).

Out with the old: The 2022 MPFS proposed rule states that CMS will replace G2064 and G2065 with the new CPT^® codes for payment. Look for confirmation of this plan in the MPFS final rule later this year, and for deletion of codes G2064 and G2065 from the HCPCS Level II code set.

Resource: Find the CY 2022 MPFS proposals in the Federal Register at www.federalregister.gov/documents/2021/07/23/2021-14973/medicare-program-cy-2022-payment-policies-under-the-physician-fee-schedule-and-other-changes-to-part.