Principal Care Management Rules Every Provider Should Know

Principal Care Management (PCM) involves Medicare-covered services for individuals who have one serious chronic condition expected to persist for at least three months. This condition should pose a risk of hospitalization or deterioration in function and must require continuous clinical oversight and coordinated care.

Qualified healthcare professionals such as physicians, nurse practitioners, and physician assistants can bill for PCM services. The provider must be directly managing the patient’s chronic condition and have frequent interaction with the patient to adjust treatment or respond to changing symptoms.

PCM services are billed using the following codes:

• CPT 99424: Used to report the first 30 minutes per month of care provided directly by a physician or qualified healthcare professional for managing a single chronic condition.
• CPT 99425: An add-on code billed for each additional 30-minute increment of physician or qualified professional time within the same month.
• CPT 99426: Reflects the initial 30 minutes of care management performed by clinical staff under the direction of a physician or other qualified professional.
• CPT 99427: Add-on code for every extra 30 minutes of clinical staff time devoted to managing the patient’s condition.

Accurate time tracking and documentation of medical necessity are required to properly support and justify billing under these codes.

PCM and CCM cannot be billed simultaneously for the same condition by the same provider. However, if different providers manage different conditions, PCM and CCM can be billed in the same month by separate providers, as long as documentation clearly reflects distinct care plans.

To ensure compliance and reimbursement, documentation must include:

• Diagnosis of the complex chronic condition
• A personalized care plan developed to address the patient’s specific chronic condition
• Time logs detailing the duration and type of services delivered each month

• Accurate records are essential to defend against audits and justify the medical necessity.

To bill PCM compliantly, providers must:

• Ensure verbal or written patient consent
• Provide monthly care coordination and management
• Maintain electronic health records (EHR)

• Do not bill alongside other care management codes unless clearly supported with separate justification
• Provide a minimum of 30 minutes of non-face-to-face services each month

Failure to meet these criteria could result in denied claims or recoupments.