Requirements for Reporting Principal Care Management
Read into the guidelines to understand proper coding of PCM services.
Most of us, at some point, have heard the phrase, “Go to the principal’s office!” Let’s keep you and your practice out of trouble by doing our homework on principal care management (PCM) codes and the guidelines surrounding their use. Read on to make sure you understand what it takes to properly bill for these services.
PCM Time Considerations
CPT® 2022 includes three new PCM codes that replace deleted HCPCS Level II comprehensive care management services codes G2064 and G2065. The new codes continue to be based on time and who is performing the service:
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 each additional 30 minutes (List separately in addition to code for primary procedure)
99426 Principal care management services, for a single high-risk disease… first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month
+ 99427 each additional 30 minutes
It is important to note that these codes can only be billed once per calendar month and are not billable at all if less than 30 minutes are documented (that goes for the add-on codes, too). It is also important to note that a provider cannot bill PCM services and other care management services in the same calendar month.
Also note that 99426 and +99427 require “direct” physician or QHCP supervision. The Centers for Medicare & Medicaid Services (CMS) defines direct supervision as requiring the physician to be immediately available, but not necessarily in the same room.
Management and support services you can include in calculating total time are:
- Establishment, implementation, revision, or monitoring of the care plan;
- Coordination of care; and
- Education regarding condition, care plan, and prognosis.
An important tip to take note of in CPT®: If the treating physician or other qualified health care professional (QHCP) performs PCM services that are not being used as supportive criteria for 99424/+99425 (or another management service), then that time can be counted toward clinical staff time to meet the elements of 99426/+99427 or another management service.
CPT® guidelines also instruct us to only count the time of one clinical staff member or provider when two or more are discussing the same patient at the same time, and to not count the time spent while performing other billable services.
There is a table located on page 68 of the American Medical Association’s CPT® 2022 Professional Edition that outlines how to bill PCM services based on how much time is documented for the calendar month. The table following it documents the unit maximum for all care management services per calendar month.
Check for Required Elements
In addition to time, the provider/clinical staff must document the following required elements, per CPT®:
- One complex chronic condition expected to last at least three months, that 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
We have a 55-year-old male patient presenting for his first preventive visit in years. Labs are ordered at this encounter, and it is discovered that the patient has a HgbA1c of 11.7. The patient is diagnosed with uncontrolled type 2 diabetes mellitus (DM2) with hyperglycemia (fulfills element one).
The provider indicates that the patient is an excellent candidate for PCM and develops a plan of care to control the DM2 (fulfills element two). It is decided that the patient will document his blood glucose before his first meal and two hours after each meal each day for one week. He is instructed to follow up with the office and instructions are given for when to call or see the doctor, or seek emergent care. Since the patient does not have experience using a glucose monitor, he is instructed to pick up the monitor at the pharmacy and return to the office that day for education on proper use by the nursing staff. For this initial encounter, the physician documents 45 minutes of service and clinical staff documents 15 minutes.
The next week, the patient comes in with his log of food and sugars, and it is decided the patient will try an oral diabetic medication and report blood glucose readings daily for three days through the patient portal. The nurse reviews the readings daily, spending five minutes per day over the course of three days, for a total of 15 minutes. On the fourth day, the doctor and nurse talk for 10 minutes discussing the readings and decide to add as-needed insulin to the care plan to lower the patient’s blood glucose (fulfills element three).
The patient returns to the office on the same day and the physician spends another 10 minutes ordering the insulin and showing the patient how to take it. At this encounter, the physician notices that the patient is being seen by a pulmonologist for obstructive sleep apnea and spends an additional 20 minutes drafting a letter to inform the specialist of the patient’s recent DM2 diagnosis and subsequent care plan (fulfills element four).
In the scenario above, we would bill 99424 with one unit of 99425 for the 85 minutes spent by the PCP. We cannot bill the clinical staff time. Per CMS, we can bill the date of service as the date the requirements are met or any date after that, but on or before the last day of the month.
Do not let the principal scare you away from billing PCM services. Just make sure you understand what we covered in this overview and complete your homework!
42 Code of Federal (CFR) 410.32(b)(3)(i) General Supervision
42 Code of Federal (CFR) 410.32(b)(3)(ii) Direct Supervision
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