Principal care management in context: PCM, TCM, CCM and RPM
Principal care management (PCM) is for non-face-to-face comprehensive care management services furnished to Medicare beneficiaries for one serious high-risk chronic condition. In order for a patient to be eligible to receive principal care management services the chronic condition needs to have the following:
- Lasted at least 3 months and is the focus of the care plan.
- Be of sufficient severity to place the patient at risk of hospitalization or have been the cause of a recent hospitalization
- Requires development or revision of disease specific care
- Requires frequent adjustments in the medication regimen and/or the management of conditions is usually complex due to comorbidities.
Principal Care Management services are usually provided by specialists and their clinical team. There are two different billing codes depending on if it is the provider or their clinical staff providing the care management services.
Other types of care management medical coding to be provided for remotely monitoring the patient through telehealth are chronic care management (CCM), remote physiologic monitoring (RPM), behavioral health integration (BHI), and general care management (GCM). Also, transitional care management (TCM) has a non-face-to-face component as well.
Concurrent Billing with Transitional Care Management
Principal care management (PCM), chronic care management (CCM), remote physiologic monitoring (RPM), behavioral health integration (BHI), and general care management (GCM) can be billed in the same month as transitional care management services (TCM).
How to Bill and Claim Remote Patient Monitoring and Principal Care Management
There are two types of remote patient monitoring services a provider can bill for in a given month. Therefore, a consent needs to be gained for the type of service you will be billing. The two (2) types of remote patient monitoring services that are billable are remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM). In order to bill a claim separately for remote physiologic monitoring, remote therapeutic monitoring, and principal care management in a given month a consent must be gained for each type of service separately to initiate the services. The consent only needs to be gained once to initiate receiving the services for the patient.
Once separate consents are gained a development of a disease specific care plan needs to be put in place before billing for ongoing principal care management services, a treatment plan needs to be put in place to before billing ongoing remote patient monitoring services, and therapy plan needs to be put in place before billing ongoing remote therapy monitoring services.
Then, once the PCM care plan, RTM treatment plan and/or RTM therapy plan are in place the recurring monthly services can be billed for PCM, RPM and RTM respectively once the complete scope of services are met.
Use 2023 Chronic Care Billing Codes
As of January 2022, PCM, RPM, RTM can all be billed in the same month. PCM and RPM services can be furnished under general supervision.When RTM services are not directly performed by the MD/DO, NP, PAs, CNS or therapist, they are furnished under direct supervision. . Based upon who is providing the services the following coding fall into place:
Principal Care Management
- CPT Code 99424: 30 to 59 minutes of a Qualified Health Professional’s time per month
- CPT Code 99425: billed along with CPT code 99424 for an additional 30 minute interval
- CPT Code 99426: 30 to 59 minutes of Clinical Staff’s time per month (approx. $61.34)
- CPT Code 99427: billed along with CPT code 99426 once for an additional 30 minute interval (approx. $47.44)
Visit the Principal Care Management Solution and Services page to find your specific locale reimbursement on the PCM calculator to see the type of recurring revenue stream you practice can generate from these services. Additionally, you can view AAPC page for further details.
Remote Physiologic Monitoring
- CPT Code 99453: Provide Set-Up, Education & Training on the Device (approx. $19.32)
- CPT Code 99091: Collecting and Analyzing Physiologic Data by a provider for a min of 30 minutes (approx. $54.52)
- CPT Code 99454: 16 Days of Monitoring (approx. $50.15)
- CPT Code 99457: Collecting & Analyzing Physiologic Data by QHP or clinical staff (20-39 minutes) (approx. $48.80)
- CPT Code 99458: Collecting & Analyzing Physiologic Data by QHP or clinical staff each additional 20 minute interval up to 2 units (approx. $39.65)
Visit the Remote Physiologic Monitoring Solution and Services page to find your specific locale reimbursement on the PCM calculator to see the type of recurring revenue stream your practice can generate from these services.
Chronic Care Management
- CPT Code 99487: Complex CCM codes require medical decision making of moderate to high complexity and establishment, implementation, monitoring or revision of a comprehensive care plan. (approx. $133.18)
- CPT Code 99489: Once the time element to bill CPT Code 99487 is met and a minimum of 90 minutes or more of CCM services is completed, then CPT Code 99489 can be billed for each additional 30 minutes of clinical staff time directed by a physician or other QHP, per month. (approx. $70.49)
- CPT Code 99490: CCM services given by clinical staff for a patient who consented (verbally or written) to CCM services, comprehensive care plan in place, scope of services requirements met as well as the time threshold between 20 to 39 minutes in a given calendar month. (approx. $62.69)
- CPT Code 99439: CCM services given by clinical staff for add on time for each 20 minute interval beyond the initial 20 minutes to bill CPT 99490 in a given calendar month. CPT 99439 can be billed up to two times in a calendar month along with CPT 99490. (approx. $47.44)
- CPT Code 99491: CCM services given by QHP for a patient who consented (verbally or written) to CCM services, comprehensive care plan in place, scope of services requirements met as well as the time threshold between 30+ minutes in a given calendar month. (approx. $85.06)
Visit the Chronic Care Management Solution & Services page to find your specific locale reimbursement on the PCM calculator to see the type of recurring revenue stream you practice can generate from these services.
Behavioral Health Integration
- CPT Code 98984: Behavioral health care planning, follow-up monitoring for behavioral health, including the use of applicable validated rating scales; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, other forms of therapy, counseling and/or psychiatric consultation (approx. $43.04)
Visit the Behavioral Health Integration Solution & Services page to find your specific locale reimbursement on the PCM calculator to see the type of recurring revenue stream you practice can generate from these services.
Remote Therapeutic Monitoring
- CPT Code 98975: Provide Set-Up, Education & Training on the Equipment (approx. $19.32)
- CPT Code 98976: RTM device(s) supply with scheduled recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 month). (approx. $50.15)
- CPT Code 98977: (RTM device(s) supply with scheduled recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each month). (approx. $50.15)
- CPT Code 98980: RTM services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the month for the initial 20 minutes of time spent. (approx. $49.48)
- CPT Code 98981: RTM services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the month for an additional 20 minutes billed along with CPT 98980. (approx. $39.65)
For RTM, CMS states the RTM CPT coding as “sometimes therapy” to allow physicians and certain Nonphysician Practitioners (NPPs, PAs, CNSs) to furnish these services outside a therapy plan of care when needed.
IF RTM services are provided by therapists, these “sometimes therapy” services are “always therapy,” and must be accompanied by the appropriate therapy modifier – GP, GO or GN — to reflect that it is under a PT, OT, or speech-language pathology plan of care, respectively.
Visit the CMS CPT Fee schedule if you would like to know the reimbursement for RTM CPT coding in your locale. Click here
Additional information on RTM is provided on CMS’ website or reviewing Medical Economics’ article.
Let CareVitality Help Your Practice Implement Guidelines for Principal Care Management
CareVitality provides PCM solutions and/or services to help implement the Principal Care Management guidelines.
CareVitality provides a comprehensive Telehealth platform to be used for CCM to bridge telehealth gaps in your practice. Additionally, our Care Team can supplement your existing team to provide turnkey telehealth services for your patients in our platform or your platform.
- Utilize CareVitality’s platform and care team
- Utilize your own platform and CareVitality’s Care Team
- License CareVitality’s platform
Learn more about CareVitality PCM Platform and services by contacting us at (800) 376-0212, emailing contact@carevitality.com or visiting Principal Care Management Solution and Services.
Also, we have many PCM Frequently asked questions below in our blog or additional guidance can be found by looking at our website page called Principal Care Management CPT Codes and other Care Management FAQs.
Frequently Asked Questions about Principal Care Management Guidelines
How long does a chronic disease management plan last?
The period of a chronic condition management plan can differ based on the individual patient’s demands and the character of their chronic condition. Chronic conditions are long-term health diseases that entail continuous care and management, so a chronic condition management plan may exist for the duration of the patient’s life.
The development of a comprehensive care plan involves a thorough assessment of the patient’s medical history, health status and current treatment plan. Based on these assessments, health care providers aim to work with the patient to establish a personalized care plan that defines monitoring techniques, goals and interventions.
To make certain that chronic condition management plan remains relevant and effective in addressing the changing health needs of the patient, it should be continuously reviewed and updated as needed. Lifestyle modifications, medication regimens and other interventions may be involved to address changes in the health status of the patient over time.
In summary, chronic condition management is a continuous approach that demands ongoing monitoring and evaluation, and the span of a chronic condition.
How often can you bill CCM?
Healthcare providers can bill for CCM services once per patient per month.
How often can you bill PCM?
Healthcare providers can bill for PCM services once per patient per month.
What is principle care management?
Principle Care Management (PCM) is a service that is designed to provide care management to patients with a single complex chronic condition such as diabetes, congestive heart failure, Parkinson’s disease, Multiple Sclerosis, and chronic obstructive pulmonary disease (COPD). PCM services are patient-centered and designed to improve health outcomes while reducing health care costs.
The objective is to prevent complications, ER visits, hospitalizations and other acute events by monitoring the patient closely and providing the appropriate interventions when needed. This can be achieved through regular assessments, care planning, care coordination of services, medication reconciliation and communication with other healthcare providers when needed.
A care management team consisting of a physician or mid-level, a care manager, and other healthcare professionals as required is usually who provide PCM. The team collaborates to develop a customized care plan that addresses the patient’s distinct needs and goals. The plan is regularly reviewed and updated as needed according to the patient’s progress.
Furthermore, PCM is typically covered by Medicare and other insurance plans.
What is the difference between PCM and CCM?
Principal Care Management (PCM) and Chronic Care Management (CCM) are two care management services codes for non face-to-face services with some similarities, but some significant differences.
Principle Care Management (PCM) is a service that is created to provide care management to patients with a single complex chronic condition. It is a patient-centered comprehensive approach focused on improving health outcomes while reducing health care expenses. It is intended to provide proactive ongoing care management and care coordination to prevent complications, and events such as ER visits and hospitalizations by monitoring patients closely and providing necessary interventions when needed.
CCM is a healthcare service to help patients with two or more chronic conditions manage, monitor and coordinate their care. Chronic conditions are long-term health conditions that need continuous management, such as diabetes, heart disease, and asthma. CCM usually involves frequent non-face-to-face services by a healthcare provider or their clinical staff and also includes medication management, and support such as coordinating care among different providers.
Key differences between CCM and PCM:
- Focus: CCM focuses on patients with two or more chronic conditions while PCM focuses on patients with a single complex chronic condition.
- Scope: CCM is a comprehensive approach patient-centered approach that covers all aspects of a patient’s health, while PCM is a specialized service focusing on a single complex chronic condition to assist patients with this specific chronic condition
- Team-based care: While both PCM and CCM emphasize team-based care, the particular team members and roles may vary based on the patient’s needs.
- Payment: CCM and PCM are billable services under Medicare and Medicare plans based on the coding and claim(s) billed.
In summary, although both PCM and CCM emphasize patient-centeredness and team-based care, CCM is a more comprehensive approach to healthcare delivery that covers all aspects of a patient’s health, while PCM is a specialized service created to assist patients with a highly complex chronic condition that can benefit from additional support.
Can CCM and PCM be billed together?
CCM and PCM services can be billed in the same calendar month provided that they are provided to the same remote patient and patient has consented to receive these services, the scope of services was met along and time requirements for each service. Usually CCM and PCM would not be billed by the same provider and are usually not completed on the same day.
What are principal care management codes?
The Principal Care Management CPT codes for principal care management are as follows:
CPT Code 99424: This code is used to bill for principal care management services for a single high-risk chronic condition provided personally by a physician or other qualified healthcare professional for the first 30 minutes per month.
CPT Code 99425: This code is used to bill for principal care management services for a single high-risk chronic condition provided personally by a physician or other qualified healthcare professional for an additional 30 minutes per month billed along with CPT 99424.
CPT Code 99426: This code is used to bill for principal care management services for a single high-risk chronic condition for the first 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional per month.
CPT Code 99427: This code is used to bill for principal care management services for a single high-risk chronic condition for an additional 30 minutes of clinical staff time directed by a physician or other qualified healthcare professional per month along with CPT Code 99426
These CPT medical codes are used to bill for principal care management services, which involve a comprehensive healthcare delivery approach that focuses on patients with a single high-risk chronic condition to improve patient outcomes and reduce healthcare costs by providing proactive and ongoing care.
How do you report 35 minutes of principal care management performed by a physician in a calendar month?
The appropriate billing code to report 35 minutes of Principal Care Management (PCM) services performed by a physician in a calendar month is CPT Code 99424. This code is used to report complex PCM services provided by a physician or other qualified healthcare professional, lasting from a minimum of 30 minutes up to 59 minutes within a calendar month
Billing 35 minutes of PCM services, CPT Code 99424, the claim must include the following:
- Service code: CPT Code 99424
- Service description: Provision of complex principal care management services by a physician or other qualified healthcare professional, lasting from a minimum of 30 minutes up to 59 minutes within a calendar month
- Time spent: 35 minutes including the exact time such as 3:00 pm to 3:35 pm CST
- Date of service: The date in which the services were provided
- Diagnosis Code for which the patient received PCM service
The billing for PCM services is covered by Medicare and Medicare Advantage plans. Moreover, since private payers may have different billing requirements and guidelines for PCM services, healthcare providers should check with each health plan to ensure that their billing practices are compliant with the health plan’s guidelines.
