Primary Care Coding Alert

Billing with other care management E/M services is probably to blame.

Maybe you implemented a principal care management (PCM) program into your practice at the beginning of this year only to be frustrated by denials. Or maybe you were daunted by the number of restrictions CPT^® has placed on the service and have decided to take a “wait-and-see” approach to adopting PCM.

Well, we’re here to tell you PCM is still a good idea. But you’re going to have to be on the lookout for current CPT^® guidelines regarding which services you cannot report with PCM if you’re going to make a PCM program work for your practice.

Here’s what you need to know.

Refresh Your PCM Knowledge

At the beginning of the year, CPT^® 2022 introduced the principal care management (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. (For other PCM criteria, see Primary Care Coding Alert, Volume 23, Issue 12).

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.

Don’t Report 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) with PCM.

And Don’t Double-Count This Time

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)

Bottom line: 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 makes good business sense for your practice despite all the CPT^® guidelines that go with it.