Launched in 2020, Principal Care Management (PCM) was introduced as the cousin of Chronic Care Management (CCM), designed to reward medical practices providing continuous care to their high risk patients with one chronic condition. Mirroring the CCM template, PCM was introduced with 2 dedicated CPT codes: G2064 (physician or other HQP) and G2065 (clinical staff).

Why should medical practices consider Principal Care Management in 2022?

Partially lost in the chaos of COVID-19 pandemic and partially due to the initial low reimbursements, we haven’t seen practices paying much attention to this new care program. Until this year.

In 2022, the PCC codes G2064 and G2065 were replaced by CPT 99424 (physician or other HQP) and 99426 (clinical staff). But the real value came from these two changes effective as of January 1, 2022:

  1. Both CPT codes got an add-on code paying for additional 30 minute increments, beyond the initial 30 minutes
  2. The reimbursement value went up by 60% in 2022 (Medicare national average payout for G2065 in 2021 was $39 where its equivalent CPT 99426 is $63 in 2022)

Download our PCC billing guide here>

What is Principal Care Management?

Principal Care Management is a non face-to-face care program designed to reimburse care provided to patients with one chronic condition that requires a disease specific care plan, frequent changes to medication and monitoring.

Which patients are eligible for Principal Care Management?

Many Medicare patients will qualify for a PCM program and practices providing Chronic Care Management already will find it easy to add Principal Care Management to their workflows. The single chronic condition in question has one or more of these characteristics:

  • Expected to last at least 3 months
  • Puts the patient at risk, resulted in a recent hospitalization or is likely result in one
  • Requires a specific care plan in order to avoid deterioration of patient’s health
  • Requires frequent adjustments in medication
  • Management of the condition is complex

What are the reimbursements for Principal Care Management?

The original CPT codes G2064 (physician or other HQP) and G2065 (clinical staff) were changed to 99424 and 99426 in 2022, and new add on-codes 99425 and 99427 were introduced, to cover additional time beyond the initial 30 minutes, when required.

Who can bill for Principal Care Management?

Both primary care providers as well as specialists caring for patients with chronic conditions are eligible to bill.

What are the general requirements for Principal Care Management?

General requirements for implementing and billing for PCM are similar to those of Chronic Care management:

  • Patient verbal agreement to participate
  • Preparation of patient’s care plan and goals
  • Documentation of care time provided
  • Documentation of time tracking and patient communication

How do you bill for Principal Care Management?

Principal Care Management provides reimbursement for the time spent managing a patient’s single high-risk condition just like Chronic Care Management in between patient’s visits (virtually). The PCM CPT codes are time based codes and are billed in 30 minutes increments. 

Do you have question about Principal Care Management? 

Download our PCM billing guide here>

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