PCM – Principal Care Management CPT Codes and other Care Management FAQs

CPT codes for principal care management are CPT 99424, 99425, 99426 and 99427.

In 2020, CMS developed CPT Code G2064 for principal care management which has been replaced by CPT Code 99424 for time spent by a physician or other qualified health care professional to bill for 30 or more minutes of time spentfor managing a patient with a single, complex chronic condition.

In 2020, CMS developed CPT Code G2065 for principal care management, which has been replaced by CPT Code 99425 for time spent by a physician or other qualified health care professional to bill for an additional 30 or more minutes of time spent in addition to CPT Code 99424 for managing a patient with a single, complex chronic condition.

Only one of the following practitioners may be paid to bill for G2064 for a given calendar month: Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners or Physician Assistants.

The difference between CPT Code 99424 and CPT Code 99426 is who is providing the principal care management service (ccm). CPT Code 99424 can be billed if the ccm services are provided by a Physician, Certified Nurse Midwife, Certified Nurse Specialist, Nurse Practitioner or Physician Assistant. CPT Code 99426 can be billed if the principal care management services are provided by the clinical staff of the Physician, Certified Nurse Midwife, Certified Nurse Specialist, Nurse Practitioner or Physician.

In 2020, CMS developed CPT Code G2064  and G2065 for principal care management which has been replaced by CPT Code 99424 and 99425 for time spent by a physician or other qualified health care professional’s care team to bill for 30 or more minutes of time spent for managing a patient with a single, complex chronic condition. CPT Code 99424 can be spent for time to bill the initial 30 minutes spent and CPT Code 99425 can be used to bill for an additional 30 minute increment.

CPT Codes for chronic care management are CPT 99490, 99439, 99487 99489, 99491, 99437 and G0506.

CPT Code G0506 is used for when a provider initiates a comprehensive care plan in an office visit and can complete the care plan after the office visit. G0506 can be billed with the higher level E&M visit if the provider’s effort and time surpasses the usual effort described in the initial visit E&M code.

In 2021, CMS developed CPT Code G2058 for chronic care management which has been replaced by CPT Code 99439 for time spent by a physician or other qualified health care professional’s clinical staff to bill for an additional 20 minutes or more minutes of time spent once CPT Code 99439 is satisfied for the initial 20 to 39 minutes for managing a patient with multiple chronic conditions.

CPT Code 99491 is for chronic care management services given by a physician or other qualified health care professional when a minimum of 30 minutes of time is spent including the full scope of services, per calendar month. In order for a patient to be eligible to bill for these services a patient must have multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient. The chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. Additionally, a comprehensive care plan has been established, implemented, revised, or monitored for the patient.

CPT Code 99437 can only be billed once in a calendar month for establishment, implementation, revision or monitoring of a comprehensive care plan.

Only one of the following practitioners may be paid for the CCM service for a given calendar month: Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners or Physician Assistants.

The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical physiologists, dentists or podiatrists, therefore these practitioners cannot furnish or bill the service. However, CMS expects referral or consultation with such physicians and practitioners by the billing practitioner to coordinate and manage care.

CPT Code 99490 for Chronic Care Management services can be billed once per calendar month once the full scope of service and a minimum of 20 minutes of time is met.

Yes, Chronic Care Management codes CPT Code 99490 and CPT Code 99439 can be billed together if the scope of service is met and the amount of time to bill Chronic Care Management services is 40 minutes or more in any given month. The CPT Code 99439 can be billed at 2 units once the threshold time spent for these services for a patient is 60 minutes or greater.

The difference between CPT Code 99490 and CPT Code 99491 is who is providing the chronic care management service (ccm).  CPT Code 99491 can be billed if the ccm services are provided by a Physician, Certified Nurse Midwife, Certified Nurse Specialist, Nurse Practitioner or Physician Assistant.  CPT Code 99490 can be billed if the chronic care management services are provided by the clinical staff of the Physician, Certified Nurse Midwife, Certified Nurse Specialist, Nurse Practitioner or Physician.

CPT Code G0511 is CPT Code used by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to bill for Chronic Care Management services once the full scope of services is met and the minimum time threshold of time is met of 20 minutes.  Usually, more time is needed to fulfill the full scope of services prior to billing for CPT G0511. Time used for reviewing Remote Physiologic Monitors can be used as part of the time since FQHCs and RHCs do not have a code specific to billing for this service.

Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill for CPT Code 99421 for online digital evaluation and management service for a cumulative time of 5 to 10 minutes spent for up to 7 days, for an established patient.

Remote Physiologic Management (RPM) Service Codes are CPT Code 99457 (initial 20 minutes of service) and CPT 99458 (additional 20 minutes of service) for clinical staff with a patient in a calendar month completing the required scope of services to bill these codes.

CPT Code 99091 is for the time by a physician or other qualified professional time collecting, analyzing and reporting physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other QHCP for a minimum of 30 minutes of time per month. Additionally, at least one communication (e.g., phone call or e-mail exchange) must be done between the physician or other QHCP and the patient to provide medical management and monitoring recommendations.

CPT Code 99453 is used to bill for the service is provide set up and training of the device.

CPT Code 99454 is used to bill for the collection and continued monitoring of the remote physiologic device(s). This monitoring must occur over at least 16-days of a 30-day period. RPM services can only be billed by one practitioner per 30-day period and cannot be reported for a patient more than once during a 30- day period (even when multiple medical devices are provided to a patient).