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

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

• 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

• Time is counted per calendar month for each patient.
• You must meet or exceed the threshold before billing:
  • 99424: First 30 minutes of physician or QHP time each month
  • 99425: Each additional 30 minutes of physician or 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 activities (phone, video, portal messaging with patient/caregiver) and non-face-to-face management tasks (reviewing test results, updating care plan, coordinating with other providers), as long as they relate to the PCM condition.
• Time spent 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

Create, monitor, or revise a disease‑specific care plan for the condition.

“Development, monitoring, or revision of a disease‑specific care plan …” (AMA)

How CCN Health’s Care Plan Feature Meets These Requirements:

• Centralized Documentation: Each patient’s disease‑specific plan is stored in the CCN Health platform, ensuring updates and revisions are logged and auditable.
• Communication Integration: Care plan activities are linked to documented two‑way communications (phone calls, portal messages, telehealth visits). The platform prompts staff to record the contact and topic addressed.
• Medication Management: The care plan module tracks current medications, adjustments, and rationales. When clinicians update doses or therapies, changes are reflected in the plan and communicated to the patient/caregiver.
• Coordination Across Providers: CCN Health allows secure notes and shared care plan access for collaborating clinicians (e.g., cardiology, primary care, pharmacy), supporting the AMA descriptor’s requirement for provider‑to‑provider communication.
• Patient/Caregiver Engagement: Printable or electronic care plans can be shared with patients or caregivers, documenting goals, progress, and next steps. This supports CMS expectations for patient access and engagement.
• Audit-Ready: Each care plan update logs date, time, staff member, and activity type—ensuring compliance if reviewed by CMS or payers.

In short, the CCN Health care plan functionality does more than meet the “develop/monitor/revise” requirement—it ties together the other PCM elements (communication, medication management, coordination, and documentation) into one workflow.*
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5) Medication Management

Perform frequent medication adjustments or manage unusually complex therapy.

“Frequent medication adjustments … or unusually complex management due to comorbidities.” (AMA)
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6) Communication & Coordination

We encourage at least 1 two‑way communication with the patient or caregiver each month for PCM.

“Ongoing communication and care coordination with the patient/family/caregiver and other treating health professionals.” (AMA)

The AMA CPT® code descriptors explicitly include ongoing communication as a core service element. CMS’s MLN booklet does not explicitly mention this, leaving room for interpretation. To reduce audit risk, CCN Health applies the conservative AMA‑based standard.

Acceptable forms of communication include:

• Live phone calls
• Telehealth or video visits
• Secure portal messaging (with patient/caregiver response)
• In‑person interactions outside of regular E/M visits
• Care coordination calls or secure messaging with other treating clinicians (documented)

7) Billing Restrictions

• No double billing: The same practitioner cannot bill both PCM and CCM for the same patient in the same month.
• Different practitioners may bill: PCM may be billed by one practitioner (for a single high‑risk condition) while another practitioner bills CCM (for multiple conditions), as long as services are not duplicated.

“CCM and PCM cannot be billed by the same practitioner for the same patient in the same month.” (CMS)

• Same practitioner may not bill PCM and CCM for the same patient in the same month; different practitioners may coordinate different conditions.

“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

• Bill monthly when medically necessary.

“You can provide PCM services monthly if the patient needs them.” (CMS)

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