These codes are time-based CPT codes, used to report care management activities during a calendar month.
The Centers for Disease Control and Prevention (CDC) reports that 6 in 10 Americans live with at least one chronic disease, like heart disease, cancer, or diabetes. These and other chronic diseases are the leading causes of death and disability in America, and they also contribute significantly to healthcare costs.
Beginning in 2020, the Centers for Medicare & Medicaid Services (CMS) created a new program called Principal Care Management (PCM). PCM represents services that focus on the medical and or physiological needs manifested by a single complex chronic condition expected to last at least three months, and includes establishing, implementing, revising, and monitoring a care plan specific to that single disease.
Due to gaps identified by CMS in coding and payment for care management services for patients with only one chronic condition, they established G codes, G2064 and G2065, which describe care management services for such conditions. A qualifying condition was expected to last between three months and one year, or until the death of the patient. The condition may have led to a recent hospitalization and/or placed the patient at significant risk of death, acute exacerbation, or functional decline. These G codes became effective in 2020, with no specialty restriction placed on the use of these codes.
The CPT code set for 2022 includes over 400 new, revised, or deleted codes, including four new codes for reporting PCM services. With the addition of these Category I CPT codes, CMS discontinued HCPCS G2064 and G2065, effective Jan. 1, 2022. These new codes are part of the Care Management Services subsection within the Evaluation and Management section of the CPT book.
There are three general categories of care management services: chronic care management, complex chronic care management, and the new code set for PCM. Each of these services is further subdivided by those services that are performed personally by the physician or non-physician practitioner and those services that are performed by the clinical staff, directed by the physician or non- physician practitioner.
The following elements are required for billing/reporting PCM services:
- One complex chronic condition expected to last at least three months that places the patient at significant risk for hospitalization, exacerbation, functional decline, or death;
- The condition requires development, monitoring, or revision of a disease-specific care plan;
- The condition requires frequent adjustments in medication and/or management and is unusually complex due to comorbidities; and
- Ongoing communication and care coordination between relevant practitioners furnishing care is necessary.
There are two new codes, 99424 and 99425, for PCM services provided by the physician or non-physician practitioner, and two new codes, 99426 and 99427, for PCM services provided by clinical staff, directed by the physician or non-physician practitioner. These codes are time-based CPT codes, and are used to report care management activities during a calendar month. Within the parenthetical notes you will find instructions for compliant billing of these services.
Care management services, including PCM services, are management and support services for a patient residing at home or in a domiciliary, rest home, or assisted living facility. These services are designed to improve care coordination, reduce avoidable hospital admissions, and improve patient engagement, resulting in better outcomes for the patient and reduced healthcare costs.
Our role as documentation integrity and coding professionals is to educate physicians and non-physician practitioners about these new codes, the documentation requirements for reporting them, and the payment available for providing these services.