Principal Care Management Billing Codes For FY 2022

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Principal Care Management Billing Codes For FY
2022
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Principal Care Management Billing Codes For FY
2022

• The Principal Care Management (PCM) service was
  created by the Centers for Medicare and Medicaid
  Services (CMS) in 2020. The aim of the program
  was to allow for provision of additional care to
  patients with a single chronic condition. In
  2022, there are four new codes to bill PCM
  services that replace two existing codes for
  these services. Under the new PCM codes,
  specialists may now be reimbursed for providing
  their patients with care management services that
  are more targeted within their own particular
  area of specialty.
• New PCM Codes for 2022
• In 2022, four new PCM codes replace the two
  previous PCM codes (HCPCS codes G2064 and G2065)
• CPT code 99424 PCM services for a single
  high-risk disease first 30 minutes provided
  personally by a physician or other qualified
  health care professional, per calendar month
• CPT code 99425 PCM services for a single
  high-risk disease each additional 30 minutes
  provided personally by a physician or other
  qualified health care professional, per calendar
  month
• CPT code 99426 PCM, for a single high-risk
  disease first 30 minutes of clinical staff time
  directed by physician or other qualified health
  care professional, per calendar month
• CPT code 99427 PCM services, for a single
  high-risk disease each additional 30 minutes of
  clinical staff time directed by a physician or
  other qualified health care professional, per
  calendar month
• Earlier HCPCS Codes (Comprehensive Care
  Management Services)

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Principal Care Management Billing Codes For FY
2022
HCPCS Code 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 HCPCS Code 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 of sufficient
severity to place patient at risk of
hospitalization or have been 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
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Principal Care Management Billing Codes For FY
2022

• Requirements for Billing PCM Services
• CMS has set forth several requirements that must
  be met for billing PCM codes for services
  provided to a patient. Important conditions
  include
• The billing practitioner must be a physician or a
  qualified health care practitioner.
• PCM services should not be reported by the same
  practitioner simultaneously with other care
  management services.
• The billing practitioner should document ongoing
  communication and care coordination between all
  practitioners providing care to the patient.
• According to the Final Rule, the expected outcome
  of the provision of PCM services is for the
  patients condition to be stabilized by the
  treating specialist so that overall care can be
  returned to the patients primary care
  practitioner.
• Consent The patients informed consent can be
  obtained verbally or in writing and should be
  documented in the patients medical record.
• For new patients and patients not seen within a
  year prior to initiation of PCM, the billing
  practitioner must conduct an initiating visit
  with the patient to educate the patient on PCM
  and obtain the patients informed consent. This
  visit can be an annual wellness visit (AWV) or
  other separately billable visit.

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Principal Care Management Billing Codes For FY
2022
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