Consider Incorporating Principal Care Management Services Into Your Practice

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Recently this author/consultant was honored to present a Medicare reimbursement update seminar for a large group of physicians and surgeons who expanded their businesses to manage patients with chronic wounds/ulcers. Early in the seminar, the attendees shared the challenges they face trying to manage the care for patients across the continuum of care, especially those with chronic conditions such as peripheral arterial disease. Therefore, these patients often receive inconsistent care from various specialties and various agencies.

Multiple attendees explained that several years ago they investigated using the 2 Care Management Services codes (Chronic Care Management Services and Complex Chronic Care Management Services) to report their clinical staff’s work, as well as their personal work. All the Care Management Services codes include establishing, implementing, revising, or monitoring the care plan, coordinating the care of other professionals and agencies, and educating the patient or caregiver about the patient’s condition, care plan, and prognosis. However, those 2 codes could only be used 1) if the patient had 2 or more chronic conditions expected to last a least 12 months, or until the death of the patient, and 2) if the chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. In addition, the physician or other qualified health care professional (QHP) was required to establish, implement, revise, or monitor a comprehensive care plan for all the needed services for all the patient’s medical conditions, psychosocial needs, and activities of daily living.

Then I asked the attendees if anyone had heard of the third and newest Care Management Service codes, Principal Care Management (PCM) Services, that were created in 2022. Although no one in the room knew anything about these new codes, everyone was interested in learning more, which was evident from the considerable number of questions that followed. By the end of our discussion, the attendees seemed excited about formalizing PCM Services into their practices because many of them were already providing, but not billing for the services described by the new PCM Services codes.

In case these new PCM Service codes are also unknown to the Business Briefs readers, let us review the major questions that were asked by the physicians and surgeons.

Q:       Which patients are eligible for PCM Services?

A:       Patients are eligible for PCM Services if they have a single high-risk condition (such as peripheral artery disease) that requires frequent adjustments in medication and/or is unusually complex due to comorbidities, that is expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death. Like the other 2 Care Management Services, the physician/QHP is required to develop, monitor, and revise a disease-specific care plan and the PCM Services must include ongoing communication and care coordination between the relevant practitioners who are furnishing care to the patient for that single high-risk condition.

Q:       Are there any patient-specific eligibility criteria?

A:       Yes, patients may be eligible if they have a significant risk of hospitalization, if they had a recent hospitalization, and/or if changes in their condition result in a referral(s).

Q:       When the Care Management Services codes were originally created in 2013, they were mostly for reporting clinical staff services. Is that true for the new PCM Services?

A:       No, there are separate PCM Service codes for clinical staff and for physicians and other QHPs. The clinical staff must meet the incident-to guidelines and their work must be directed under general supervision of the physician/QHP.

Q:       Is the physician/QHP who is directing the PCM Service required to inform the patient that this service is being provided?

A:       Yes, the physician/QHP should explain the service and obtain the patient’s written or verbal consent before beginning PCM Services for that patient.

Q:       Should the physician/QHP, who is providing the PCM Services, involve other practitioners and agencies in their care plans?

A:       Absolutely yes! In fact, the physician/QHP should share the patient’s care plan with the patient and their caregiver(s), and with all the practitioners and agencies who will be providing care for this single high-risk condition.

Q:       If I want to formalize the PCM Services into my practice, are there any process or workflow requirements?

A:       Yes, as already mentioned, the patient must provide written or verbal consent. The required information must be documented in a certified electronic health record (EHR). The physician/QHP must provide access to clinical staff 24/7, the clinical staff should have access to the patient’s medical record (including the plan of care) outside of business hours, and the clinical staff must be physically in the U.S. In addition, the physician/QHP must manage the patient’s care transition throughout the continuum of care.

Q:        The Plan of Care appears to be a particularly important requirement for PCM Services. What information is required in the Plan of Care?

A:        The 2023 Current Procedural Terminology (CPT^®)¹ Codebook has an extensive Care Planning section, which itemizes elements that may be included in the Plan of Care. However, the codebook emphasizes: 1) that the list of elements are only a guide because the Plan of Care should be unique and meaningful to each patient, 2) that the Plan of Care should include specific and achievable goals for each condition, and should be measurable, 3) that the Plan of Care should be updated as often as needed, but must be reviewed and revised at least every year, and 4) as stated above, that the Plan of Care should be shared with patients, caregivers, and all professionals providing care to the patient.

Q:       What are the unique PCM Service codes for clinical staff and for physicians/QHPs?

A:       The PCM Services codes for physicians/QHPs are 99424 for the first 30 minutes and 99425 for each additional 30 minutes per calendar month. The PCM Services codes for the clinical staff are 99426 for the first 30 minutes and 99427 for each additional 30 minutes per calendar month. NOTE: Clinical staff time cannot be included when reporting 99424 and 99425, but physician/QHP time can be included when reporting 99426 and 99427—if the physician/QHP did not report 99424/99425.

Q:       Because PCM Services are reported per calendar month, what information should be documented to support the PCM Services provided to each patient?

A:       In order to report the correct PCM Service codes, each clinical staff member, each physician, and each QHP should identify themselves and document every activity, and the time spent on the activity, throughout the month. The activities should include such items as all contacts with the patient, updates to the care plan, and assessments of the patient’s status.

Q:       If the time spent performing PCM Services is less than 30 minutes, can the physician, QHP, or clinical staff still report PCM Services?

A:       No. A full 30 minutes of services must be performed before PCM Services can be billed.

Q:       I understand that the base PCM Services codes for physicians/QHPS (99424) and clinical staff (99426) should only be reported once per calendar month. How often are the add-on codes allowed to be reported per calendar month?

A:       The CPT Codebook does not state a limit for the physician/QHP add-on code (99425), but it does limit the clinical staff add-on code (99427) to twice per calendar month.

Q:       Because PCM Services are disease-specific, can different physicians/QHPs report PCM Services for managing different diseases in the same calendar month?

A:       Yes, different physician/QHPs and different clinical staff can report PCM Services for different diseases in the same calendar month, if the PCM Services are thoroughly documented in the patient’s EHR and clearly describe the coordination among the relevant managing clinicians.

Q:       Does the Medicare Physician Fee Schedule include published rates for the PCM Services codes?

A:       Yes. See Table 1.

Q:       Do Medicare patients incur a charge for PCM Services?

A:       Yes, Medicare patients or their secondary payer will incur a 20% copayment for PCM Services.

Q:       Are the Medicare Administrative Contractors (MACs) covering PCM Services?

A:       Yes—if the guidelines are followed and the required documentation is in the EHR. In fact, multiple MACs have presented webinars pertaining to PCM Services, as well as the 2 other Care Management Services. The MACs are making huge attempts to encourage services that lead to less fragmented health care, fewer emergency room visits, fewer hospital stays, lower out of pocket costs for patients, more time for in-person visits, etc. Be sure to visit your MAC’s website to view the plethora of information about these important services. In addition, be sure to read the 2023 CPT^® Codebook Care Management Services section, and to visit the American Medical Association’s website where you will find excellent resources pertaining to this topic.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.

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Reference
1. Current Procedural Terminology (CPT)^® is a registered trademark of the American Medical Association. Copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.