Description: Principal care management (PCM) focuses on managing a single chronic condition that puts patients at risk for hospitalization, decline or death. PCM services may be expected to last 6months to 1 year or until death. 

Delivery Method: Face-to-face, phone or video

Who Can Bill? Physicians, and non-physician practitioners (Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Midwives). Clinical staff activities are included under the supervision of the billing practitioner.  

Payer
Code    
Billing Allowance  		DescriptionRequirements
Medicare99424
 
  • 30-minutes of service per calendar month of non-face to face services performed by physician
  • Only 1 practitioner can bill per Medicare beneficiary
  • Cost-share may apply
     
  • Patients with a single or more complex conditions
  • Be expected to last at least 6 months- 1 year or death
     
  • Patient Consent (verbal or written)
    • Must be received at least once and documented.
  • Initiating Visit
    • Conducted once within the past three years.  
    • Medicare AWV may qualify as the initial visit if the provider performed and will be responsible for APCM services.
  • 24/7 Access and Continuity of Care
  • Patient-Centered Comprehensive Care Management Services
  • Patient-Centered Care Plan
  • Management of Coordination of Care (transitions)
  • Enhanced communication opportunities
     
99425
  • Add on for additional 30 minutes of time.  
  • Can be billed unlimited number of times 
     
9942630- minutes of service per calendar month of non-face to face services performed by clinician 
99427Add on code to 99426 for additional 30 minutes 

*For additional details regarding requirements please reference CMS guidelines*  

MICMT does not have expertise related to the Centers for Medicare and Medicaid services coverage decisions related to billing. The information contained on this site comes from publicly available sources of CMS information. Any needed clarification should come from CMS or their representatives/contractors. 


Reference Materials