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Billing for Principal Care Management

Billing for Principal Care Management

Basics of Principal Care Management (PCM)

PCM is similar to chronic care management (CCM) in a way, both services are for patients who require ongoing clinical monitoring and care coordination. However, unlike its CCM counterpart, PCM only requires patients to have one complex chronic condition; CCM requires three or more. For example, PCM could be appropriate for a patient with uncontrolled diabetes or uncontrolled hypertension or a high-risk patient with severe asthma who has frequent hospital readmissions. It could also be necessary for someone with hepatitis C, fibromyalgia, long-haul COVID-19 or a variety of other complex chronic conditions.

Many practices are already doing this work to take care of these patients, they just need to capture the right information so they can bill for it. This information includes details such as disease-specific care plans, adjustments in medication regimens ongoing communication with specialists and more. Internists who treat a high volume of Medicare patients should definitely consider providing and billing for all care management services, including transitional care management (TCM), CCM and PCM because this population tends to struggle with at least one chronic condition and frequent hospitalizations.

Billing for Principal Care Management

Choose Right Patient

Not every patient with a complex chronic condition requires PCM. Make sure you’re documenting that the condition is severe enough that the patient is at risk for hospitalization or was recently hospitalized several times due to that condition. The biggest reason for recoupment is that diagnoses for which CCM is performed don’t meet billing criteria or Medicare program integrity rules; and it may be true for PCM. For example, physicians can’t bill PCM for patients with a well-controlled chronic condition.

Consider a patient who is admitted to the hospital with uncontrolled hypertension. The patient may require TCM for 30 days after discharge, followed by PCM for an additional 30 days or more. If the patient develops an additional complex chronic condition that requires ongoing monitoring, they may even be eligible for CCM instead of PCM. Note that CCM is also a 30-day service for a patient with two or more chronic conditions expected to last at least 12 months that place the patient at significant risk of death, acute exacerbation/decompensation or functional decline.

Choose Accurate CPT Code

Report CPT codes 99424 and 99425 when a physician or nonphysician provider performs the PCM, and report CPT codes 99426 and 99427 when clinical staff under the direct supervision of a physician or other qualified health care professional provide the service. Clinical staff might include an RN, clinical psychologist or medical assistant. However, physicians need to check with payers and state nursing boards before billing because every state is different.

CPT 99424

Principal care management (PCM) performed by a physician or nonphysician provider 30 minutes per calendar month

CPT 99425

Additional 30 minutes per calendar month

CPT 99426

PCM performed by clinical staff under the direction of a physician or other qualified health care professional 30 minutes per calendar month

CPT 99426

Additional 30 minutes per calendar month

Supporting Documentation

Documentation must include, name, time spent, what providers done specifically and their credentials. And be sure to document that you’ve notified the patient that their coinsurance applies. You can take assistance of EHR (electronic health records) also, just ensure if that EHR supports a care management workflow.

If you feel like if you are already providing Principal Care Management (PCM) services but doesn’t have technical expertise to bill them, then we can assist you. Medisys Data Solutions is a leading medical billing company providing medical speciality wise billing and coding services. Our services include medical coding, benefits verification, charge entry, payment posting, denial management, AR management, provider credentialing, and enrollment. To know more about our PCM billing and coding services, contact us at 302-261-9187

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