Oncology & Hematology Coding Alert

Here’s how to get paid for the work your practice does for your sickest patients.

In Oncology and Hematology Coding Alert volume 23 number 9, we briefly described Medicare’s new codes for a new form of care management — principal care management, or PCM — that will become effective on Jan. 1, 2022.

PCM will become a significant model for your practice to manage your chronically ill patients with single conditions. So, here is some expert guidance on how to code the service from Samuel L. “Le” Church, MD, MPH, CPC, CPC-1, CRC, FAAFP’s 2021 HEALTHCON Regional Conference presentation, “Understanding Principal Care Management and Changes to the Care Management Code Family.”

Lesson 1: Learn What’s Meant by Chronic

First, let’s look at the codes and see what the services entail:

• 99424 (Principal care management services, for a single high-risk disease: with the following required elements: one complex chronic condition expected to last at least 3 months, and which places the patient at significant risk of hospital­ization, acute exacerbation /decompensation, functional decline, or death, the condition requires development, monitoring, 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; 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 …)
• 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 (… each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional …).

The first element of the descriptor tells you that PCM is reserved for patients with a single chronic condition expected to last 3 months that “places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline or death.” This is important, as PCM services “are about keeping people out of emergency rooms and hospitals,” Dr. Church says.

Additionally, per CPT^®, a condition is “treated as chronic whether or not stage or severity changes.” In other words, a condition is chronic no matter what its severity or whether it is stable, in a state of exacerbation, or in a stage of progression.

Lesson 2: Learn What’s in a Care Plan

Per CPT^®, this should be “based on a physical, mental, cognitive, social, functional, and environmental evaluation,” and should include, but not be limited to, the following:

• Problem list
• Expected outcome and prognosis
• Measurable treatment goals
• Cognitive assessment
• Functional assessment
• Symptom management
• Planned interventions
• Medication management
• Environmental evaluation
• Caregiver assessment
• Intervention and coordination with outside resources and other health care professionals and others, as necessary
• Summary of advance directives.

Importantly, “the care plan is not a list of requirements, and some things don’t fit. For example, pediatric patients will probably not need advance directives,” Church observes.

Lesson 3: Learn What Does and Does Not Count Toward PCM

“Just about anything in support of the care plan can be reported,” Church says. That even includes the creation or updating of the plan. However, you cannot double-dip services such as transitional care or home health oversight, and even though you can bill for office or hospital evaluation and management (E/M) services, they must be separate and significant to treatment outlined in the care plan.

Most important, however, PCM services will need to follow the office requirements as currently identified in CPT^®. This includes 24/7 patient access to physicians or other qualified healthcare professionals (QHPs), use of an electronic medical record (EMR) system with a format standardized throughout the practice, and a designated member of the care team responsible for providing continuity of care.

Lesson 4: Learn Who Can Bill PCM

You can bill for PCM when provided directly by a physician or another QHP such as and physician assistants (PAs), certified registered nurse practitioners (CRNPs), or clinical nurse specialists (CNS), physicians or other QHPs themselves with 99424/+99425. And you can also bill for PCM provided by clinical staff — medical assistants, 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 by using 99426/+99427.

Billing tip: “With PCM, it’s important to note that more than one provider can bill. This is not true of chronic care management (CCM). Also, only physicians, QHPs and clinical staff can claim time. Front office staff cannot, even though they may be involved in such activities as scheduling,” Church pointed out.

Lesson 5: Learn PCM Time Parameters and How to Bill

Lastly, perhaps the most difficult thing about implementing PCM services into your practice is figuring out how to bill for them. For one thing, “some practices do not even document care management time, so the codes cannot even be used,” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. To remedy this, Bucknam suggests coders “create a process to track it or create a special build in your electronic medical record (EMR) to track and calculate minutes spent providing the service.”

More, you need to remember that the codes are for each calendar month, so you should “count time over the course of the month and not bill what you have done on the last day of the month with same date of service,” Church says. Additionally, “time doesn’t roll over from month to month,” Church cautions.

The final word: “As all tasks consistent with care plan can be billed, including charting, and you are already doing this work, why not get paid for it? And even though it’s not about all about the money but about patient outcomes, we’re spending a lot of money on healthcare, and now we’re trying to get better outcomes. So, this is money wisely spent,” Church says.