Principal Care Management Services: 99424 – 99427

Principal Care Management new codes for Physicians or other qualified healthcare professionals

The CPT Editorial Panel also created new codes for principal care management (99424, 99425, 99426, 99427), which allow physicians and qualified health care rofessionals to report care management services for patients with one complex chronic condition.

99424 – Principal care management services, for a single high-risk disease with the following required elements:

• One complex chronic condition expected to last at least 3 months, and that places the patient at significant of hospitalization, acute exacerbation decompensation, functional decline or death,

• Condition requires development, monitoring or revision of the disease specific care plan,

• Condition requires frequent adjustments in medication regimen and/or regimen and/or the management of the condition is usually complex due to comorbidities

• Ongoing communication and care coordination between relevant practitioners furnishing care; First 30 minutes provided personally by a physician or other qualified
health care professional; per calendar month

+99425 – Each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

Note:

** Use 99425 in conjunction with 99424.

** Principal care management services of less than 30 minutes in a calendar month are not reported separately.

Principal Care Management new codes for clinical staff time:

** 99426 – Principal care management services, for a single high-risk disease with the same required elements as code 99424 (see previous slide). First 30 minutes of clinical staff time directed by a physician or other qualified health care professional; per calendar month.

** +99427 – each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional; per calendar month (List separately in addition to code for primary procedure)

Note:
** Use 99427 in conjunction with 99426.
** Principal care management services of less than 30 minutes in a calendar month are not reported separately.

Chronic Care Management Services:

** +99437 – Each additional 30 minutes by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for primary procedure.

Use 99437 in conjunction with 99491. Do no report 99437 for less than 30 minutes

Principal Care Management Services

For calendar year 2020, the Centers for Medicare and Medicaid Services (CMS) introduced two new HCPCS codes to describe care management services for a single, complex chronic condition. These codes differ from Chronic Care Management Services(CCM) which focus on the care of two or more chronic conditions.

A qualifying condition for Principal Care Management (PCM) servicesmay be expected to last between three months to one yearor until the death of the patient. The initiation of a PCM service will typically be triggered by an exacerbation of the patient’s chronic condition or recent hospitalization.

The patient’s primary care physician will still supervise the patient’s overall care, but a specialist will manage services for the specific chronic condition.

HCPCS Code Descriptions

G2064– Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements:

▪ One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
▪ The condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization,
▪ The condition requires development or revision of disease-specific care plan,
▪ The condition requires frequent adjustments in the medication regimen, and/or
▪ The management of the condition is unusually complex due to comorbidities

G2065– Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements:
▪ One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
▪ The condition is ofsufficientseverity to place patient at risk of hospitalization or have been the cause of a recent hospitalization,
▪ The condition requires development or revision of disease-specific care plan,
▪ The condition requires frequent adjustments in the medication regimen, and/or
▪ The management of the condition is unusually complex due to comorbidities