In the Medicare Physician Fee Schedule final rule issued last November, the Centers for Medicare and Medicaid Services (CMS) added four new CPT codes in the category of Principal Care Management (PCM) to replace the two previous PCM codes (HCPCS codes G2064 and G2065). These codes may be an additional revenue opportunity for allergists caring for patients with severe, high-risk asthma who meet required criteria as they will add monthly payments above existing E/M codes. This is a win-win for both allergists and patients. CMS’ goal is to improve care for these complicated patients and keep them out of the hospital, and it is willing to pay physicians more to make that happen.
PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. The four new PCM codes are intended to reimburse physicians for the additional work they do caring for high risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up and more. These codes may be used for allergists treating patients with severe, uncontrolled asthma who meet the required criteria outlined below.
The new PCM codes, which became effective Jan. 1, are described as follows:
2022 Medicare Reimbursement for PCM Codes
| Code | Descriptor | *2022 Non-Facility National Payment Amount |
|---|---|---|
| 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 | $83.40 |
| 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 | $60.22 |
| 99426 | PCM services 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 | $63.33 |
| 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 | $48.45 |
| * Please refer to the Physician Fee Schedule Look-Up Tool to determine local non-facility payment amounts. | ||
Note: CPT codes 99424 and 99425 are for time spent by a physician or other qualified health care professional.
CPT codes 99426 and 99427 are for clinical staff time directed by a physician or other qualified health care professional.
It is also important to note that provider/clinical staff time does not have to be face-to-face time. It can be time used to create care plans, follow-up with patients via phone, etc.
Patients covered by PCM codes must meet the following criteria defined by CMS:
- They have one complex chronic condition lasting at least three months.
- The condition is severe enough that the patient is at risk for hospitalization or was recently hospitalized due to the condition.
- The condition requires development or revision of a 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.
As with prior PCM codes, patients must consent to receive PCM services, and patients are responsible for the 20% beneficiary cost-sharing requirement for the services.
Allergists using these codes are not required to assume complete care of the patient for other, unrelated diagnoses, although co-morbidities should be taken into consideration during treatment.
When billing these codes, it is important that allergy practices document:
- Ongoing communication and care coordination between the specialists and patients.
- That patients meet the above criteria. The disease-specific care plan should be included in the patient’s chart, along with documentation of medication adjustments, patient communications, etc.
- The amount of time spent providing care each month.
This article addresses Medicare fee-for-service payment rules. Providers should refer to the policies of other payers to verify coverage.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
