Principal Care Management
A monthly care-management service for a single, high-risk chronic condition, aimed at specialists and generalists managing one complex problem rather than a whole patient panel.
What it is
Principal Care Management (PCM) pays for monthly, non-face-to-face care management focused on a single complex chronic condition expected to last at least three months and that puts the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death.
Unlike Chronic Care Management, which covers a patient's overall care across two or more conditions, PCM is scoped to one condition, which makes it a common fit for specialists (cardiology, nephrology, pulmonology, and similar) as well as primary care managing a single dominant problem.
Who qualifies
- Patient has one complex chronic condition expected to last at least 3 months
- The condition 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, medication management, and coordination with other treating practitioners
- Documented patient consent to PCM services
Codes at a glance
| Code | What it covers | Threshold | Approx. payment | Details link |
|---|---|---|---|---|
| 99424 | First 30 minutes of physician or qualified health professional time, per calendar month | 30 minutes physician/QHP time | ~$88 | Details → |
| 99425 | Each additional 30 minutes of physician or QHP time (add-on to 99424) | Each additional 30 minutes physician/QHP time | ~$61 | Details → |
| 99426 | First 30 minutes of clinical staff time directed by a physician or QHP, per calendar month | 30 minutes clinical staff time | ~$68 | Details → |
| 99427 | Each additional 30 minutes of clinical staff time (add-on to 99426) | Each additional 30 minutes clinical staff time | ~$54 | Details → |
Approximate CY2026 Medicare Physician Fee Schedule national non-facility payment benchmark for non-QP clinicians, before geographic, sequestration, and claim-specific adjustments. Actual reimbursement varies by locality, practitioner status, payer, and billing circumstances. Verify the applicable amount with CMS or your Medicare Administrative Contractor.
What's required to bill
- Documented patient consent (verbal consent is acceptable) covering cost-sharing and the nature of the service
- A disease-specific care plan for the single qualifying condition, established, monitored, and revised as needed
- 24/7 access to the care team for urgent needs related to the condition
- Medication management specific to the condition
- Coordination with other practitioners treating the patient, including sharing the care plan
- Only one practitioner bills PCM for a given condition, patient, and month
Documentation checklist
- Consent to PCM services
- A written, condition-specific care plan
- Time log showing physician/QHP time (99424/99425) or clinical staff time directed by a physician/QHP (99426/99427)
- Evidence of coordination with other treating practitioners
- Medication management notes tied to the qualifying condition
Common billing mistakes
- Billing PCM and CCM for the same patient with the same practitioner in the same month, only different practitioners (e.g., a PCP billing CCM while a specialist bills PCM for a distinct condition) may bill both concurrently, each with a separate care plan and no duplicated time
- Billing the add-on code (99425 or 99427) without first meeting the base code's 30-minute threshold
- No condition-specific care plan on file
- More than one practitioner billing PCM for the same condition in the same month
- Vague documentation that doesn't tie the time logged to the single qualifying condition
FAQ
Can PCM be billed alongside Chronic Care Management (CCM) for the same patient?
The same practitioner cannot bill both CCM and PCM for the same patient in the same month. Different practitioners can: for example, a primary care practitioner bills CCM while a specialist bills PCM for a separate condition, each maintaining its own care plan with no duplicated time or activity between the two.
What condition qualifies for PCM?
A single, complex chronic condition expected to last at least three months that puts the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death: for example, a recent heart failure diagnosis being actively titrated, or complex COPD.
Does PCM require physician time, or can staff time count?
Both are billable, but under different codes: 99424/99425 for physician or other qualified health professional time, and 99426/99427 for clinical staff time directed by a physician or QHP.