Unlike some other “care management” codes that require the physician manage a patient from head to toe, principal care management (PCM) is applicable to a specialty practice such as ophthalmology. This may be a useful addition to your retinal practice.

Q. What is principal care management?

A. Principal care management is an intensive, non–face-to-face service for high-risk patients. The Centers for Medicare and Medicaid Services (CMS) defines PCM as “services that focus on the medical and/or psychological needs manifested by a single, complex chronic condition expected to last at least 3 months and includes establishing, implementing, revising, or monitoring a care plan specific to that single disease.” CMS considers PCM reasonable and necessary when all of the following criteria are met:

• Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member;
• Furnished in a setting appropriate to the patient’s medical needs and condition;
• Ordered and furnished by qualified personnel;
• One that meets, but does not exceed, the patient’s medical need; and
• At least as beneficial as an existing and available medically appropriate alternative.

Principal care management would not be reasonable or necessary for minimal-risk, low-risk, or moderate-risk patients. The levels of risk are extensively discussed and defined in the evaluation and management (E/M) code set in relation to problems and management. PCM codes are found within the category E/M services, so these definitions are pertinent.

PCM may be provided by a physician or other qualified healthcare professional (QHP). Additionally, PCM can be provided by clinical staff directed by a physician or QHP.

Q. What is “high risk” in this context?

A. A high-risk condition has one or more of the following characteristics:

• Patient needs emergency major surgery within 24 hours
• Patient needs immediate hospitalization
• Patient needs medical care within 24 hours
• Patient needs to be examined by her ophthalmologist frequently (daily or every few hours)
• Patient’s disease(s) or condition(s) has unusual features that make it much more risky than normal, such as
  • Head injury,
  • Abnormal anesthesia risk,
  • Failure of a prior surgery, or
  • Patient is monocular
• Blindness or serious loss of vision is imminent.

The key concepts are threat to sight or life, and urgent need for medical/surgical care. For example, age-related macular degeneration takes many forms, which vary in risk. It’s not accurate to say that AMD is always a high-risk condition.

Q. What are the required elements of PCM?

A. According to CMS, principal care management personally provided by a physician or other qualified healthcare professional for a single high-risk disease requires:

• “One complex chronic condition that is expected to last at least 3 months, and places the patient at significant risk of hospitalization, acute exacerbation/decompensation, or functional decline, or death;
• The condition requires development, monitoring, 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;
• Ongoing communication and care coordination between relevant practitioners furnishing care.”

For example, you might consider PCM for a 35-year-old patient with neuromyelitis optica and associated optic neuritis who is treated with intravenous, high-dose corticosteroids and plasma exchange, followed by oral immunosuppressants and rituximab.

Q. How is PCM reported on a claim?

A. In 2022, we have 2 new sets of CPT codes: 99424 and 99425 for PCM personally provided by a physician or QHP, and 99426 and 99427 for PCM provided by clinical staff directed by a physician or QHP. For both code pairs, the first code includes for the first 30 minutes of care time in a calendar month, while the second code is for each additional 30 minutes in the same month.

Do not report 99424/99425 in the same calendar month as 99426/99427. Also, the G-codes introduced in 2020 are no longer applicable now that 9942X have been added.

Q. What is Medicare’s allowable fee for PCM?

A. In 2022, the national Medicare Physician Fee Schedule includes the following. These amounts are adjusted by local wage indices in each area.

• Physician-performed      99424 — $83     99425 — $60
• Physician-supervised     99426 — $63     99427 — $48

Q. Can PCM be combined with other services?

A. Principal care management, as described in CPT, may be combined with certain other services, so long as the time spent is not counted twice for reporting purposes.

Q. What documentation is required to support a claim for PCM?

A. It requires at least 30 minutes of time per calendar month.

PCM is only ordered by a physician or QHP who is treating the patient, following an eye exam. The order must appear in the clinical record in a specific care plan for the patient. Key elements within the note include expected duration of the disease, risk factors, care regimen and changes to it, and communication with other practitioners furnishing care.

Physician time spent in a calendar month is cumulative, so individual entries in the chart during the month are summed. RP