The Advocacy Council has received several inquiries regarding the proper use of Current Procedural Terminology (CPT) codes 99424, 99425, 99426, and 99427 describing Principal Care Management (PCM) services. These PCM codes and their corresponding Medicare reimbursement levels are described as follows:
| Code | Descriptor | *2022 Medicare 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. | ||
Patients covered by PCM codes must meet ALL the following criteria:
- They have one complex chronic condition expected to last at least three months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death.
- 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.
- There is ongoing communication and care coordination between relevant practitioners furnishing care.
The four PCM codes above 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 above. However, it is unlikely that routine oral immunotherapy (OIT) services would satisfy the above criteria for purposes of Medicare billing.
For additional guidance on coding for OIT services, please refer to our prior guidance.
Allergists billing PCM codes need to document carefully that patients meet the above criteria. For instance, the disease-specific care plan should be included in the patient’s chart, along with documentation of medication adjustments, patient communications, etc.
Additionally, allergy practices should document the amount of time spent providing care each month. The provider/clinical staff time does not have to be face-to-face time, but can be time used to create care plans, follow-up with patients via telephone, etc.
Providers should refer to the policies of other, non-Medicare payers to verify coverage.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS
