2023 Medicare PCM Reimbursement Updates

Are you familiar with the Principal Care Management (PCM) program and its associated CPT codes for Medicare? If you’re a healthcare provider looking to properly bill for this program, then keep reading. 

PCM is a program designed to manage one chronic condition and has several billing codes associated with it. As a healthcare provider, you may only want to bill for one chronic condition even if the patient has multiple ones. At Lynk, we specialize in helping practices manage, bill and streamline reimbursements for CMS programs like PCM. 

So, what are the updates for PCM and its CPT codes in 2023? While there aren’t any major changes in the rule and regulation in CMS’ 2023 final rule, there are updated reimbursement rates for the CPT codes. These codes are based on national averages, which may vary in your area. For the exact current rate based on your location, you can visit the Physician Fee Schedule website. 

There are four CPT codes in total for PCM and they’re broken down into two series based on who provides the services: one for provider time and the other for clinical time. Let’s dive into the codes. 

The first CPT code for provider time is 99424, which is for 30 minutes of non-face-to-face PCM services. The current national average reimbursement rate is $81. Additionally, there is an add-on code, 99425, which can be billed on top of the 99424 for an additional 30 minutes of non-face-to-face provider time. This has a national average reimbursement rate of $58. So for both codes, you can bill a total of 60 minutes for $139. 

The first clinical code for PCM is 99426, which is for 30 minutes of non-face-to-face time done by the clinician. This includes certified resources or higher who are not providers at your practice. The national average reimbursement rate for this code is $61. Additionally, there is an add-on code, 99427, which is billed after 30 additional minutes of clinician time. This code has a national average reimbursement rate of around $47. So for both codes, you can bill a total of 60 minutes for $108. 

Now that you have a better understanding of PCM and its CPT codes, what should you do next? 

We hope this has been helpful for you as a healthcare provider looking to properly bill for the PCM program. If you have any further questions or need assistance with managing and billing for PCM, feel free to reach out to us at info@lynkhealthcare.com.