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Principal Care Management (PCM) is a Centers for Medicare & Medicaid Services (CMS) care management reimbursement model that pays physicians and qualified health care professionals (QHPs) for comprehensive, non-face-to-face monthly care coordination focused on a single high-risk or complex chronic condition. Unlike Chronic Care Management (CPT 99490), which requires two or more chronic conditions lasting at least 12 months, PCM (billed under CPT codes 99424, 99425, 99426, and 99427) is designed for specialty practices and primary care teams stabilizing a single complex illness expected to last at least 3 months.
What Is Principal Care Management (PCM)?
CMS introduced Principal Care Management in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule (originally under HCPCS codes G2064 and G2065) and transitioned the program to four permanent AMA CPT codes (99424–99427) in CY 2022. PCM addresses a major structural gap in longitudinal Medicare reimbursement: patients who have only one qualifying chronic disease—or whose clinical instability is driven overwhelmingly by a single complex condition managed by a specialist (such as heart failure managed by cardiology, brittle type 1 diabetes managed by endocrinology, severe COPD managed by pulmonology, or active rheumatoid arthritis managed by rheumatology)—previously could not qualify for two-condition CCM or needed dedicated single-disease stabilization.
To qualify for Principal Care Management under CMS billing guidelines, the patient’s clinical presentation must meet four statutory criteria:
- Single Complex Chronic Condition: The patient has one complex chronic condition expected to last between 3 months and 1 year, or until the death of the patient.
- Acute Risk of Decompensation: The condition places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death, or has required a recent hospitalization or emergency department visit for disease stabilization.
- Disease-Specific Care Plan: The condition requires development, monitoring, or revision of a disease-specific care plan focused on that targeted condition.
- Active Regimen Adjustment or Co-Management: In practice, the condition requires frequent adjustments in the medication regimen, or the management of the condition is unusually complex due to comorbidities and requires ongoing communication and care coordination between the treating specialist and the patient’s primary care practitioner.
Principal Care Management CPT Codes: 99424, 99425, 99426, and 99427
AMA CPT divides Principal Care Management codes into two distinct billing tracks based on who performs the cumulative monthly time during a calendar month: personal time spent by the billing physician or QHP (NP, PA, CNS, CNM) versus clinical staff time (RN, LPN, MA, care coordinator, pharmacist) working under the general supervision of the billing practitioner.
| CPT Code | Code Type | Personnel Performing Time | Monthly Time Threshold | Supervision & Billing Rules |
|---|---|---|---|---|
| CPT 99424 | Base Code (Primary) | Physician or other Qualified Health Care Professional (QHP) personally | First 30 minutes per calendar month | Requires personally performed physician/QHP work; cannot combine clinical staff minutes to reach the 30-minute threshold. |
| CPT 99425 | Add-On Code (+) |
Physician or other QHP personally | Each additional 30 minutes per calendar month (60+ total minutes for 1 unit) | Must be billed in addition to primary code 99424 on the same claim. |
| CPT 99426 | Base Code (Primary) | Clinical staff directed by a physician or other QHP | First 30 minutes per calendar month | Permits auxiliary personnel working under general supervision (42 CFR § 410.26) when incident-to requirements are met. |
| CPT 99427 | Add-On Code (+) |
Clinical staff directed by a physician or other QHP | Each additional 30 minutes per calendar month (60+ total minutes for 1 unit) | Must be billed in addition to primary code 99426; reported for a maximum of two add-on units per calendar month under CPT rules. |
Non-Overlapping Track Rule: A single billing practitioner cannot report both the physician/QHP track (99424/99425) and the clinical staff track (99426/99427) for the same patient in the same calendar month. However, physician/QHP personal time can be counted toward the clinical staff codes (99426/99427) if the physician spends less than 30 minutes personally and elects to combine their time with clinical staff minutes to meet the 99426 threshold (the reverse is strictly prohibited: clinical staff time can never be counted toward 99424).
CMS Eligibility, Disease-Specific Care Plan, and Billing Guidelines
Audits by Medicare Administrative Contractors (MACs) and the HHS Office of Inspector General (OIG) verify that every PCM claim satisfies five mandatory operational and documentation elements:
- 1. Initiating Visit Requirement (New Patients or Unseen >1 Year): For patients not seen by the billing practitioner within the preceding 12 months, PCM must be initiated during a comprehensive face-to-face Evaluation and Management (E/M) visit, an Annual Wellness Visit (AWV), or an Initial Preventive Physical Examination (IPPE). The initiating visit is billed separately, and time spent during that E/M encounter cannot be double-counted toward the 30-minute monthly PCM threshold.
- 2. Advance Patient Consent (Verbal or Written): Before furnishing or billing PCM services, the practitioner must obtain and document the patient’s verbal or written consent in the electronic health record (EHR). The consent disclosure must inform the beneficiary of the availability of PCM services, that standard Medicare Part B cost-sharing (20% coinsurance and annual deductible) applies to each monthly claim, that the beneficiary has the right to stop PCM services at any time (effective at the end of the calendar month), and whether another practitioner is concurrently managing other conditions.
- 3. Certified EHR and 24/7 Clinical Access: The practice must record structured patient demographics, problems, medications, and medication allergies using ONC-certified EHR technology, provide the patient with 24/7 access to physicians or QHPs to address urgent needs related to the target chronic condition, and maintain continuity of care with designated care team members.
- 4. Comprehensive Disease-Specific Care Plan: Unlike a general wellness summary, a PCM care plan must document the target diagnosis (ICD-10-CM), measurable treatment goals, symptom management protocols, planned interventions, medication reconciliation and adherence tracking, and identification of all external clinicians and community services involved in the patient’s care. A copy of the disease-specific care plan must be shared with the patient and/or caregiver.
- 5. Time-Log Auditability and Non-Duplication: Every logged PCM entry in the EHR must record the date of service, the exact duration in minutes, the credentialed individual performing the activity, and a summary of the clinical coordination performed. Time cannot be double-counted with Remote Patient Monitoring (RPM, CPT 99457/99458, as used on platforms like Tenovi), Transitional Care Management (TCM, CPT 99495/99496), or Advanced Primary Care Management (APCM, HCPCS G0556–G0558).
Principal Care Management (PCM) vs. Chronic Care Management (CCM)
Health systems and specialty groups frequently evaluate whether a patient should be enrolled in Principal Care Management (PCM) or Chronic Care Management (CCM). Furthermore, under CMS rules, a specialist can bill PCM for a single complex condition in the same calendar month that a primary care physician bills CCM for the patient’s broader chronic comorbidities—provided both practitioners manage distinct clinical scopes, coordinate care with one another, and never double-count the same minutes.
| Comparison Dimension | Principal Care Management (PCM) | Chronic Care Management (CCM) |
|---|---|---|
| Qualifying Chronic Conditions | 1 complex chronic condition placing the patient at risk of hospitalization, acute decompensation, or functional decline. | 2 or more chronic conditions placing the patient at significant risk of death, acute exacerbation, or functional decline. |
| Expected Condition Duration | At least 3 months (up to 1 year, or until death). | At least 12 months (or until the death of the patient). |
| Clinical Staff Base & Add-On Codes | CPT 99426 (first 30 min clinical staff) + CPT 99427 (each additional 30 min). | CPT 99490 (first 20 min clinical staff) + CPT 99439 (each additional 20 min). |
| Physician/QHP Base & Add-On Codes | CPT 99424 (first 30 min physician/QHP) + CPT 99425 (each additional 30 min). | CPT 99491 (first 30 min physician/QHP) + CPT 99437 (each additional 30 min). |
| Care Plan Scope | Disease-specific care plan focused on stabilizing the single target condition and coordinating with the PCP. | Comprehensive person-centered care plan addressing all health issues, psychosocial needs, and preventive care. |
| Typical Billing Specialty | Medical and surgical specialists (cardiology, pulmonology, endocrinology, oncology, neurology, rheumatology) or PCPs managing 1 condition. | Primary care (internal medicine, family medicine, geriatrics) and multispecialty longitudinal care teams participating in MIPS or ACOs. |
Frequently Asked Questions
What is Principal Care Management?
Principal Care Management (PCM) is a Medicare Part B care management service (CPT codes 99424, 99425, 99426, and 99427) that reimburses physicians and qualified health care professionals for at least 30 minutes per calendar month of non-face-to-face care coordination, medication adjustments, and disease-specific care plan management for a patient with a single high-risk chronic condition expected to last at least 3 months.
What is the difference between CPT 99424 and CPT 99426?
Both CPT 99424 and CPT 99426 require at least 30 minutes of Principal Care Management services in a calendar month, but they differ by who performs the work: CPT 99424 applies when a physician or qualified health care professional (NP, PA, CNS) personally performs all 30 minutes of care management, whereas CPT 99426 applies when clinical staff (such as an RN, LPN, or medical assistant) perform the 30 minutes under the general supervision of the billing practitioner.
Can a patient receive Principal Care Management and Chronic Care Management in the same month?
Not from the same practitioner—a single billing practitioner cannot bill both PCM and CCM for the same beneficiary in the same calendar month. However, CMS permits a specialist to bill PCM for a single unstable condition (for example, a cardiologist managing acute heart failure titration) in the same month that a different practitioner (such as the patient’s primary care physician) bills CCM for the patient’s other chronic conditions, provided their care plans are coordinated and time is never duplicated.
