Medicare Compliance & Reimbursement

Ensure PCM billing compliance with a thorough knowledge of current CPT^® guidelines.

Whether you’ve already implemented a principal care management (PCM) program or are in the beginning stages, the process can be daunting. Incorporating PCM into your practice can make a lot of sense, but make sure you’re aware of which services you can and cannot report, according to current CPT^® guidelines.

Remember What Exactly PCM Means

At the beginning of the year, CPT^® 2022 introduced PCM codes:

• 99424 (Principal care management services, for a single high-risk disease … first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month)
• +99425 (Principal care management services … each additional 30 minutes provided personally by a physician or other qualified health care professional …)
• 99426 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)
• +99427 (Principal care management services … each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional …)

“A patient would be eligible for PCM if they have a complex 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,” says Lori Carlin, CPC, COC, CPCO, CCS, director, professional coding services, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

But following this patient criteria and the other extensive, required criteria CPT^® has established in the code descriptors for PCM is not the only obstacle you need to overcome before your PCM program operates like a well-oiled machine. You also need to pay attention to a significant number of other services that you cannot report with PCM, either because the services, or the service times, overlap.

Know These Restrictions on Reporting These Services

To begin, you cannot bill 99424/+99425 with 99426/+99427 or vice versa in the same calendar month. As the code descriptors note, the providers for the services differ, with 99424/+99425 being performed by physicians or qualified healthcare professionals (QHPs) and 99426/+99427 by clinical staff under a physician’s or QHP’s direction.

Don’t forget: “A CPT^® coding tip tells you that if the physician personally performs PCM activities, but the physician time doesn’t reach the 30-minute threshold for 99424, then the physician’s time can be counted toward the clinical staff time required for 99426/+99427,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Additionally, you won’t be able to report PCM with 99490/+99439 and 99491/+99437 (Chronic care management …) or 99487/+99489 (Complex chronic care management …) in the same calendar month, as patient eligibility criteria for chronic care management (CCM) or complex CCM — multiple (two or more) chronic conditions expected to last at least 12 months — differ from the patient condition eligibility for PCM.

CPT^® also tells you not to report end-stage renal disease (ESRD) related services (90951-90970); care plan oversight services (99339/99340, 99374-99380); and medication therapy management services provided by a pharmacist (99605- +99607) together with PCM.

Watch Carefully for Overlap

One of the other difficulties in launching or maintaining a care management program of any kind is tracking the time spent performing the services outlined in the code descriptors and guidelines. But even trickier is making sure the time a provider spends on those care management services does not overlap with any other services that provider may offer the same patient at the same time.

That’s why CPT^® guidelines contain a second, extensive list of services for which you cannot simultaneously report PCM service time. Unlike the codes above, you may report the codes in this second list for the same patient in the same calendar month as PCM, but the time reported for the following patient education and training codes cannot be the same time counted toward PCM:

• INR training and anticoagulant management (93792- 93793)
• Patient self-management training (98960-98962)
• Educational supplies (99071)
• Educational services rendered to patients in a group setting (99078)

The same is true for these evaluation/assessment management services:

• Online digital evaluation and management service (99421- 99423)
• Telephone evaluation and management service (99441- 99443)
• Telephone assessment and management (98966-98968)
• Qualified nonphysician health care professional online digital assessment and management (98970-98972)
• Medication therapy management services provided by a pharmacist (99605-+99607)
• Prolonged evaluation and management service before and/ or after direct patient care (99358-+99359)
• Special reports, such as insurance forms (99080)
• Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) (99091)
• Medical team conference (99366-99368)

Business sense: With average Medicare national nonfacility fees ranging from $83.40 for 99424 to $63.33 for 99426 per patient per calendar month, a PCM program may make good business sense for your practice, despite all the CPT^® guidelines that go with it.