The condition is expected to have the following:

Think of PCM as a “single-condition” version of Chronic Care Management (CCM), which applies to patients with two or more conditions.

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📋 PCM Requirements

To bill PCM under CPT codes 99424–99427, meet these elements. Each item includes a supporting quote from CMS (MLN or FAQs) or AMA (CPT® descriptor language as published/licensed):

1) 🗓️ Initiating Visit

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Perform a face-to-face initiating visit when PCM starts; renew with a new initiating visit after 12 months to continue.
“After 1 year, we require another initial visit to continue the services.” (CMS)

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2) 🩺 Patient Eligibility

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Patient has one serious/high-risk chronic condition expected to last ≥3 months with significant risk.
“PCM services focus on a single, high-risk chronic condition expected to last at least 3 months … at significant risk of hospitalization … or death.” (CMS)

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3) ⏱️ Time Thresholds
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Time is counted per calendar month for each patient. You must meet or exceed the threshold before billing:

• 99424: First 30 minutes of physician/QHP time each month
• 99425: Each additional 30 minutes of physician/QHP time
• 99426: First 30 minutes of clinical staff time (under physician/QHP supervision)
• 99427: Each additional 30 minutes of clinical staff time
  Time may include both direct communication (phone, video, portal messaging with patient/caregiver) and non-face-to-face management tasks (reviewing results, updating the care plan, coordinating with other providers) so long as they relate to the PCM condition.
  Time must be exclusive to PCM and not double-counted toward CCM, RPM, or other time-based codes in the same month.
  “You can’t bill for PCM services of less than 30 minutes per calendar month.” (CMS)*

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4) 🧭 Care Plan
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Create, monitor, or revise a disease-specific care plan for the condition, including problem list, goals, symptom tracking, interventions, medication management, and caregiver input. (Paraphrased—no CPT descriptor text.)

How CCN Health’s Care Plan Feature Supports PCM

• Centralized Documentation: Each patient’s disease-specific plan is stored with version history so updates/revisions are logged and auditable.
• Communication Integration: Care plan activities link to documented two-way communications (phone, portal, telehealth), and staff are prompted to record the contact and topic.
• Medication Management: Tracks current meds, adjustments, and rationales; changes are reflected in the plan and shared with the patient/caregiver.
• Care Team Coordination: Secure notes and shared plan access for collaborating clinicians (e.g., cardiology, primary care, pharmacy) to support coordinated care.
• Patient/Caregiver Engagement: Printable/electronic plans document goals, progress, and next steps, supporting patient access and engagement expectations.
• Audit-Ready: Each update logs date, time, staff member, and activity type for compliance review.

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5) 💊 Medication Management
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Perform frequent medication adjustments or manage complex therapy (e.g., due to comorbidities), with reconciliation, monitoring for interactions/side effects, and adherence support. (Paraphrased—no CPT descriptor text.)

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6) 🔄 Communication & Coordination
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Maintain ongoing communication and care coordination with the patient/family/caregiver and other treating professionals. Many programs include at least one two-way touchpoint each month as a best practice to document active management.
Acceptable forms include: live phone calls; telehealth/video visits; secure portal messaging with response; in-person interactions outside E/M visits; and documented provider-to-provider coordination that’s relayed to the patient.

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7) 🚫 Billing Restrictions

• No double billing: The same practitioner cannot bill PCM and CCM for the same patient in the same month.
• Different practitioners may bill: One practitioner may bill PCM (for the single high-risk condition) while another bills CCM (for multiple conditions), as long as services aren’t duplicated.
  “CCM and PCM cannot be billed by the same practitioner for the same patient in the same month.” (CMS)

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8) 📅 Frequency (CMS)
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Bill monthly when medically necessary and all time and service elements are met.
“You can provide PCM services monthly if the patient needs them.” (CMS)

* If your local MAC instructions differ, follow your MAC’s policy and document the source.

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