Pediatric Coding Alert

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

Georgia Subscriber

Answer: 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 qualified healthcare professional (QHP), may provide the services, which you would document with 99426 (Principal care management services … first 30 minutes …) and +99427 (… each additional 30 minutes …).

Activities that you can count toward these codes include developing, monitoring, or revising a disease-specific care plan. The 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.

One familiar caveat, however, is to be sure not to double-dip services. Transitional care or home health oversight are commonly billed incorrectly, and even though office or hospital evaluation and management (E/M) services are fair game, they must be separate and significant to the treatment outlined. That means you’ll need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the PCM code.

Remember: Certified registered nurse practitioners (CRNPs), clinical nurse specialists (CNSs), physician assistants (PAs) and other clinical staff can also perform these services providing the services are conducted under the direction of a physician or QHP. You would document these encounters using 99424 (Principal care management services, … first 30 minutes …) and +99425 (… 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 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.