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Supported Line of Business: Medicare Advantage

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PCM covers patients with one complex chronic condition. For patients with two or more chronic conditions, see Service Line Guide: Chronic Care Management (CCM).

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Overview

Principal Care Management (PCM) services were established by CMS in the CY 2022 Physician Fee Schedule (PFS) Final Rule and became billable starting January 1, 2022. PCM is designed to support Medicare patients with a single complex chronic condition through intensive, condition-focused care management — including care plan development, medication management, and between-visit coordination.

Unlike CCM, which requires two or more chronic conditions, PCM is specifically designed for patients whose care needs are dominated by one serious, complex chronic condition. PCM services can be delivered either directly by a physician or other qualified health care professional (QHP), or as incident-to services by clinical staff under the general supervision of a billing practitioner.

Bridge recommends the billing practitioner meet face to face with the patient at least annually in order to assess the patients condition(s) and enrolled program appropriateness.

There are no standalone National or Local Coverage Determinations (NCDs/LCDs) specific to PCM — the policies are governed primarily through the annual PFS final rules.

To qualify for PCM, a patient must have:

• One complex chronic condition,
• Expected to last at least 3 months or until the patient's death, and
• A condition that places the patient at significant risk of hospitalization, nursing home admission, acute exacerbation/decompensation, functional decline, or death.

There are two billing pathways for PCM, distinguished by who delivers the care management time:

1. Physician/QHP-Provided Time (99424, 99425): The billing practitioner personally provides the care management time. Requires at least 30 minutes of physician or QHP time per calendar month.
2. Clinical Staff Time (99426, 99427): Clinical staff provide the care management time incident-to, directed by a physician or QHP. Requires at least 30 minutes of clinical staff time per calendar month.

Consent requirements

Service Frequency

Billing requirements

Chronic Conditions

CPT Codes

Submitting services to Bridge