Series Part III: Principal Care Management Basics

Knee pain

Photo Credit: Pexels

The key difference between Chronic Care Management and Principal Care Management (PCM) is that the focus of the care management is for the medical and/or psychological needs related to a single, complex chronic condition (e.g., total joint replacement).

In order to qualify for PCM services, the patient must have a single, complex chronic condition expected to last at least three months.

Examples of Principal Care Conditions:

  • Joint Replacement
  • Complicated Diabetes
  • Multiple Sclerosis
  • Advanced Heart Disease
  • Parkinson’s Disease
  • COPD (Chronic Obstructive Pulmonary Disease)
  • Severe Asthma

PCM services for a single high-risk disease require the following:

  1. ONE complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death
  2. The condition requires development, monitoring, or revision of disease-specific care plan
  3. The condition requires frequent adjustments in the medication regimen and/or the management of the condition is usually complex due to comorbidities
  4. Ongoing communication and care coordination between relevant practitioners furnishing care
  5. Documentation of dates/times
  6. Once time threshold has been met, claim may be submitted

CPT Codes

(PCM) Principal Care Management

  • 99424: First 30 minutes of care management by a physician or (OQHP) other qualified healthcare professional (Novitas $84.82)
  • +99425: Each additional 30 minutes of care management (Novitas $61.41)
  • 99426: First 30 minutes of clinical staff time, directed by a physician or qualified healthcare professional (Novitas $63.55)
  • +99427: Each additional 30 minutes of clinical staff time (Novitas $48.35)

CPT coding is determined by who provided PCM for the calendar month and requires a minimum of 30 minutes dedicated to Principal Care Management services.

Documentation

  • List of patient’s problems and conditions
  • Expected outcomes/prognosis with measurable treatment goals
  • Cognitive and functional assessments
  • Symptom management
  • Planned interventions (with identification of individuals responsible for interventions)
  • Medication management
  • Environmental evaluation
  • Caregiver assessment
  • Coordination with outside resources and providers
  • Requirements for periodic review and revision of plan
  • Referrals applicable to condition
  • Support of referral by creating and exchanging summary of care document

Consent

Patients must give consent to receive PCM services. This can be given in written or verbal form and documented in the medical record.

The medical record consent documentation must include:

  1. The patient’s consent to participate in PCM,
  2. That the patient was informed that she/he can stop receiving PCM services at any time, and
  3. That only one health care professional or hospital can provide PCM in a calendar month.

Information about applicable cost sharing should be included as well.

Series Part IV:  Transitional Care Management (coming soon)

Resources

Medicare.gov Principal Care Managment Services

CodeCast Podcast: Principal Care Management

NGS Medicare: Principal Care Management Services