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CMS Principal Care Management 2022 – New CPT Codes – HealthArc

The Centers for Medicare and Medicaid Services (CMS) proposed four new Principal Care Management CPT codes to classify care management for a single, complicated chronic disease.

These codes differ from Chronic Care Management Services(CCM), which manage two or more chronic illnesses.

These codes may be an extra revenue opportunity for allergists or healthcare professionals caring for patients with severe, high-risk asthma as they will add monthly payments exceeding ongoing E/M codes.

What is Principal Care Management (PCM)?

Principal Care Management CMS is a system that indexes or assigns interventions to patients with a chronic condition in the continuum of treatment and care.

It includes health checks, regular screenings, utilization assessments, event monitoring, short-term care coordination, and long-term chronic health condition management.

The eligibility condition for Principal Care Management (PCM) services can last between three months and one year or until the patient’s demise. PCM service is often initiated in response to a patient’s chronic disease progression or recent hospitalization.

Principal Care Management CPT Codes in 2022

The four new CMS Principal Care Management 2022 codes compensate physicians’ extra hours caring for high-risk, complex patients.

These include the additional time and effort required for changing prescriptions, developing a care plan, patient follow-up, and other duties.

The new Principal Care Management CMS 2022 codes, which became effective from Jan. 1, are described as follows:

99424 (Services for Initial 30 Minutes by Physician)

  • For a single chronic condition
  • Per calendar month, services are provided for the first 30 minutes by a physician or other certified healthcare practitioner.

99425 (Services for Each Additional 30 Minutes by Physician)

  • For a single chronic illness
  • Per calendar month, services are provided by a physician or other competent healthcare practitioner for each extra 30 minutes after 99424.

99426 (Services for Initial 30 Minutes by Clinical Staff Time)

  • For a single chronic ailment
  • Initial 30 minutes of clinical staff service time per calendar month, as directed by a physician or other authorized healthcare provider.

99427 (Services for Each Additional 30 Minutes by Clinical Staff Time)

  • For a single chronic disease
  • Additional 30 minutes of service time each calendar month after 99426 hours of clinical staff guided by a physician or other competent healthcare practitioner.

How Does Principal Care Management Work?

First, a certified health care professional (typically a health practitioner or physician assistant) develops a disease-specific treatment plan and then makes any required changes.

These continuing modifications are anticipated and incorporated into the payment standards; for example, qualifying conditions are specified as needful “frequent revisions in the pharmaceutical regimen.”

Following that, clinical personnel, such as nurses, operate under the supervision of a physician or certified health care practitioner to carry out the treatment plan.

These include explicitly monitoring and managing the patient’s condition and medicines, regular contact, coordination with the patient, and other day-to-day delivery duties.

4 Benefits of HealthArc – CMS Principal Care Management 2022

There are benefits of Principal Care Management for both patients and healthcare providers. Let’s look at the advantages of adopting HealthArc software for PCM services:

  • Effective Care Plan Generation with EHR Integration

Develop, modify, and update patient-centered care plans easily. HealthArc seamlessly integrates with the market’s top 55 EHRs. Aside from EHRs, HealthArc connects with any device that supports external APIs, such as Bluetooth or cellular devices.

  • Supports Multiple Conditions

HealthArc is a clinician-friendly software that is designed to improve health standards and help you address the requirements of patients comprehensively by analyzing respiratory system status, musculoskeletal system status, and therapy compliances.

  • Improves Clinical Decision Support

HealthArc has a dedicated Security & Compliance team to ensure privacy is incorporated into our staff, systems, and third-party interactions. All our components, including the patient interaction module, SMS, and in-app messaging, are HIPAA compliant.

  • Concurrent Billing with Other Services – RPM, RTM & TCM

The HealthArc platform allows providers to simultaneously provide RPM, RTM, and TCM care management services. Principal Care Management can be billed concurrently with remote patient monitoring as long as the monitored time is not billed twice.

What are Principal Care Management Guidelines in 2022?

Patients covered by PCM codes must fulfill the following principal care management guidelines defined by CMS:

  • They must have a long-term chronic illness that has lasted at least three months.
  • The patient’s condition is bad enough that they are at risk of being admitted to the hospital or have already been admitted.
  • A disease-specific care plan must be developed or revised for this illness.
  • The disease necessitates a regular drug regimen, or the condition care is extremely complicated due to co-diagnoses.

Clinics must document the following when invoicing these codes:

  • The records of communication and care coordination between specialists and patients are ongoing.
  • To fulfill the requirements listed above. The patient’s file should include the disease-specific treatment plan, as well as documentation of medication modifications, patient communications, and so on.
  • The amount of time spent each month providing care.

Do not bill CMS Principal Care Management 2022 codes when:

  • Only medically directed staff provided chronic care management.
  • Below 30 minutes of the time is spent monthly.
  • Already billed for one time.
  • The time spent on the service is reported as transitional care management services.

CMS Principal Care Management 2022 Code and Reimbursement

CPT Code Billable Time  Reimbursement Rate
 99424  30 min  $83.40
 99425  60 min  $60.22
 99426  30 min  $63.33
 99427  60 min  $48.45

Time spent by a physician or other authorized health care practitioner is coded as CPT codes 99424 and 99425.

Clinical staff time directed by a physician or other authorized health care professional is coded as CPT codes 99426 and 99427.

It is also worth mentioning that the time spent by providers and clinical personnel need not be face-to-face. It can include setting up care plans, calling patients for follow-up, etc.

How to Bill and Claim for Principal Care Management

When submitting a claim using CMS, you must provide the following from your records:

  • CPT codes for each program you’re in charge of and ICD-10 codes for each of the conditions you’re in charge of.
  • Service start date
  • Service location
  • Name of the service provider

While it isn’t required, knowing the care manager assigned to a patient is useful in the event of an audit: When it comes to billing, you’ll keep track of the time you spend with each of your patients every month.

When billing, you’ll follow these four steps:

  • Each month, double-check that CMS standards were satisfied for each patient.
  • Must submit CMS claims every month.
  • Patients who get CCM services should receive a monthly invoice.
  • Make sure no conflicting codes are billed.

FAQ for Principal Care Management CPT Codes

1. When should I not bill these codes?

Never bill these codes in case:

  • Medically dedicated staff itself provides chronic care management and not some chronic care management provider (use 99439, 99490)
  • Consultation of less than 30 minutes is given to the patient
  • Consults are more than two within one month
  • Given time goes under transitional care management services (99495-99496)

2. What is the ROI of a Principal Care Management Program?

ROI is often seen in terms of finance gained back, whereas the ROI of the Principal Care Management Program lies more in terms of benefits. PCM provides a preventive eye on patients. Their well-being can be monitored, and advanced measures can be taken in light of any fluctuations in the vitals to abnormal values.

3. How does Principal Care Management Program help in improving the quality of care my practice provides?

CCM lets you provide care to patients within their homes. This helps reduce the service burden on your staff and facilities. With lesser or shared burden, you can utilize and allocate your resources more skillfully, focusing on improving the quality of care you and your practice can provide.

4. How does Principal Care Management Program help in reducing the burden of chronic conditions?

Chronic illnesses need immediate attention when there’s a rise in illness. When the symptoms go away, some constant monitoring is still needed.

Principal Care Management Program provides help in addressing the broad implications of chronic diseases. Thus, the burden of chronic conditions and additional illnesses and health complications reduces.

5. How does Principal Care Management Program help in improving MPIS scores?

Principal Care Management Program helps in reducing the patient’s emergency visits. The extent of preventive care through the Principal Care Management Program helps in reducing the occurrence of the medical condition.

With a reduction in patient visits, some essential criteria of performance indicators measured by Medicare stay well within limits, thus helping you in keeping and improving your Merit-based Incentive Payment System (MIPS) score.

A good MPIS score further increases your reimbursement rate.

6. How does Principal Care Management Program help in improving patient relations and care experience?

Principal Care Management Program allows meeting patients on a monthly basis. Meeting patients frequently, almost every month strengthens the bond with them. Patient engagement improves and thus results in a better care experience and more trust.

Also Read: 2022 CPT Codes for Remote Patient Monitoring by CMS

Conclusion: Maximize Your Revenue & Revamp Principal Management Care Services With HealthArc

Indeed, as a healthcare practitioner, you aim to provide the best healthcare to patients. Of course, you want to receive fair compensation for the services provided.

You will need a program management system to offer and document primary care services.

A useful solution, such as healthcare management software, will prevent important facts from being lost or overlooked. These will increase efficiency for you and your staff while helping patients succeed.

Healthcare management software can help create patient care plans, staffing procedures, and billing. HealthArc software solutions provide these special features and many more.

HealthArc’s comprehensive approach to Principal Care Management enables providers to deliver care management services for their patients suffering from specific chronic illnesses by enhancing the quality metrics of their healthcare while generating healthy revenue.

Schedule a demo today to learn more about billing and reimbursement principal care management CMS CPT codes.