Updated for 2026. Principal Care Management (PCM) gives Medicare practices a care-management pathway for patients whose needs center on one complex, high-risk chronic condition.
The four primary PCM CPT codes are 99424, 99425, 99426, and 99427. The biggest difference between them is who performs the service and whether the code represents the initial or additional 30 minutes of qualifying monthly care-management time.
Principal Care Management CPT Codes at a Glance
CPT CodeWho Performs the ServiceTimeRole99424Physician or other qualified healthcare professionalFirst 30 minutes per calendar monthBase practitioner PCM code99425Physician or other qualified healthcare professionalEach additional 30 minutesAdd-on to 9942499426Clinical staff under direction of physician or qualified healthcare professionalFirst 30 minutes per calendar monthBase clinical-staff PCM code99427Clinical staff under direction of physician or qualified healthcare professionalEach additional 30 minutesAdd-on to 99426
What Is Principal Care Management?
CMS describes PCM as care management focused on a single high-risk chronic condition that is expected to last at least three months and places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.
PCM differs from Chronic Care Management because CCM generally addresses two or more chronic conditions through a broader comprehensive care plan, while PCM centers on one principal condition requiring focused disease-specific management.
PCM Patient Eligibility Requirements
According to CMS guidance, the principal chronic condition generally should:
- Be expected to last at least three months
- Place the patient at significant risk of hospitalization
- Create risk of death, acute exacerbation or decompensation, or functional decline
- Require ongoing disease-specific management
- Require a disease-specific care plan
- Require ongoing communication and coordination among relevant practitioners
- Require frequent medication adjustments and/or unusually complex management due to the patient's circumstances or comorbidities
Having a particular diagnosis does not automatically qualify a patient for PCM. The patient's actual clinical complexity and management needs should be supported by the medical record.
CPT 99424: Practitioner PCM, First 30 Minutes
CPT 99424 is the base PCM code for services personally performed by a physician or other qualified healthcare professional.
It represents the first 30 minutes of qualifying PCM services during a calendar month.
Typical disease-specific management activities may include:
- Reviewing the patient's principal condition
- Managing a disease-specific care plan
- Medication management
- Reviewing symptoms and treatment response
- Coordinating with other practitioners
- Communicating with the patient or caregiver
- Adjusting the care-management strategy when clinically necessary
Example
A cardiologist personally spends 34 qualifying minutes during the month managing a patient's complex heart-failure care plan, reviewing medication response, coordinating treatment, and communicating with the patient.
If all other Medicare requirements are met, the documentation may support evaluation of CPT 99424.
CPT 99425: Additional Practitioner PCM Time
CPT 99425 is an add-on code used with CPT 99424 for additional qualifying practitioner PCM time.
CMS identifies it as an additional 30 minutes per calendar month.
Because it is an add-on code, CPT 99425 should not be reported independently without the applicable base PCM service.
Example
A qualified healthcare professional personally provides enough qualifying PCM management during the month to support the base 99424 service and an additional qualifying 30-minute period.
The practice would evaluate whether CPT 99424 plus CPT 99425 is supported by the documented time and all applicable billing requirements.
CPT 99426: Clinical Staff PCM, First 30 Minutes
CPT 99426 is the base PCM code for qualifying services performed by clinical staff under the direction of a physician or other qualified healthcare professional.
It represents the first 30 minutes of clinical staff PCM time per calendar month.
This structure allows practices to use a team-based approach when properly qualified clinical staff perform disease-specific care-management activities under the required practitioner oversight.
Potential Clinical Staff Activities
- Following up with the patient about the principal condition
- Monitoring implementation of the disease-specific care plan
- Medication-management support within permitted scope
- Coordinating specialist care
- Patient or caregiver education
- Identifying barriers to treatment
- Escalating clinically important findings to the practitioner
- Documenting qualifying care-management activity
The specific activities an individual may perform depend on applicable Medicare rules, state scope-of-practice requirements, professional qualifications, and organizational policy.
CPT 99427: Additional Clinical Staff PCM Time
CPT 99427 is the add-on code for additional qualifying clinical-staff PCM time after the requirements for CPT 99426 are met.
It represents each additional 30 minutes of qualifying clinical staff PCM services during the calendar month.
As with other add-on codes, the documentation should support both the base service and the additional time reported.
99424 vs 99426: What's the Difference?
The key difference is who performs the qualifying PCM services.
Feature9942499426Initial monthly time30 minutes30 minutesService performed byPhysician or qualified healthcare professional personallyClinical staff under practitioner directionAdd-on code9942599427FocusSingle complex chronic conditionSingle complex chronic condition
Your documentation should clearly identify the individual who performed each qualifying activity so the billing team can determine which code family is supported.
99425 vs 99427
Both codes represent additional PCM time, but they correspond to different base services.
- 99425 adds qualifying practitioner time to CPT 99424.
- 99427 adds qualifying clinical-staff time to CPT 99426.
Practices should not select an add-on code simply because total recorded time appears high. The documentation should show the type of qualifying service, who performed it, and that the applicable base-code requirements were met.
Medicare Does Not Pay PCM for Less Than 30 Minutes
CMS states that PCM services of less than 30 minutes per calendar month cannot be billed.
This means that recording 15 or 20 minutes of PCM activity does not by itself support one of the base PCM time codes.
Practices should track qualifying activity throughout the calendar month and review the final supported total before submitting a claim.
PCM Requires a Disease-Specific Care Plan
A disease-specific care plan is one of the defining elements of PCM.
The plan should focus on the principal condition rather than becoming a generic summary of all of the patient's medical problems.
Depending on the patient, the care plan may include:
- The principal chronic condition
- Clinical goals
- Expected outcomes
- Medication-management strategy
- Symptoms and warning signs
- Planned interventions
- Patient self-management responsibilities
- Specialist responsibilities
- Care-coordination needs
- Follow-up plan
- Relevant caregiver involvement
Example PCM Care Plan
Principal condition: Chronic heart failure
Goal: Reduce risk of decompensation and avoid preventable hospitalization.
Management plan: Monitor symptoms, review medication adherence, coordinate cardiology follow-up, reinforce the established weight-monitoring plan, assess treatment barriers, and escalate signs of deterioration.
Care coordination: Primary care practitioner, cardiologist, pharmacy, patient, and caregiver as applicable.
Follow-up: Monthly PCM activity with additional clinical follow-up based on patient status.
Does PCM Require an Initial Visit?
CMS states that PCM services can be provided monthly when the patient needs them and that another initial visit is required after one year to continue PCM services.
Practices should maintain documentation supporting the patient's ongoing relationship with the billing practitioner and confirm current Medicare requirements when beginning or continuing PCM.
Can Specialists Bill PCM?
PCM can be particularly useful for specialty practices because one specialist may be responsible for intensive management of the patient's principal condition.
Potential examples include:
- Cardiology managing complex heart failure
- Nephrology managing advanced kidney disease
- Pulmonology managing severe COPD
- Endocrinology managing highly complex diabetes
- Oncology managing a qualifying chronic cancer-related condition
The specialty itself does not determine eligibility. The patient's condition and documented care-management requirements must satisfy the applicable PCM criteria.
PCM and CCM in the Same Month
PCM and CCM serve different purposes. CCM addresses multiple chronic conditions, while PCM focuses on one principal complex condition.
CMS guidance allows separate practitioners to potentially furnish PCM and CCM concurrently when appropriate, the programs address different conditions, and all individual requirements are met.
The same practitioner should not simply report PCM and CCM for the same patient's overlapping monthly care-management work.
When separate practitioners provide PCM and CCM, their documentation should clearly distinguish:
- The conditions being managed
- The two care plans
- The staff performing each service
- The qualifying activities
- The time attributed to each service
PCM and RPM
Principal Care Management and Remote Physiologic Monitoring address different service components.
PCM focuses on disease-specific longitudinal care management, while RPM focuses on remotely collected physiologic data and associated monitoring or treatment-management services.
When a patient receives multiple programs, practices should verify that each service independently meets its requirements and avoid counting the same staff effort or time more than once when prohibited.
PCM and APCM
Advanced Primary Care Management (APCM) is another Medicare care-management model practices should consider.
CMS describes APCM as a monthly bundled primary-care service incorporating elements of several existing services, including PCM and CCM.
Because APCM includes care-management components within its monthly bundle, practices using APCM should carefully review current CMS rules before separately billing overlapping services.
PCM Documentation Checklist
- Identify one principal complex chronic condition.
- Document that the condition is expected to last at least three months.
- Document the patient's significant clinical risk.
- Support why the condition requires focused ongoing management.
- Create a disease-specific care plan.
- Document medication-management complexity when applicable.
- Document ongoing communication and care coordination.
- Identify who performed each PCM activity.
- Record qualifying time accurately.
- Separate practitioner time from clinical-staff time.
- Confirm at least the applicable 30-minute base threshold is supported.
- Verify add-on time before reporting 99425 or 99427.
- Avoid duplicate reporting of the same work or time.
- Review the service before claim submission.
Example Monthly PCM Time Record
DateActivityPerformed ByTimeOct 3Reviewed disease-specific symptoms and treatment planClinical staff9 minOct 11Medication adherence follow-up and practitioner escalationClinical staff8 minOct 18Specialist coordination and care-plan updateClinical staff7 minOct 25Patient follow-up regarding symptom-management planClinical staff8 minTotal qualifying clinical-staff time32 min
If the patient, staff, documentation, care plan, and all other applicable requirements are satisfied, the practice may evaluate whether the documented service supports CPT 99426.
Common PCM Billing Mistakes
1. Using PCM for Multiple Conditions
PCM is designed around one principal high-risk condition. Patients requiring integrated management of multiple chronic conditions may be better evaluated for CCM or another appropriate care-management model.
2. Billing Less Than 30 Minutes
CMS states that PCM services under 30 minutes per calendar month cannot be billed using the PCM time codes.
3. Mixing Practitioner and Clinical Staff Codes
99424/99425 represent practitioner PCM time, while 99426/99427 represent clinical-staff PCM. Track the person performing the service accurately.
4. Missing the Disease-Specific Care Plan
A PCM program should have documentation showing a care plan specifically focused on the principal condition.
5. Counting Administrative Work Automatically
Not every phone call, scheduling task, or chart action automatically qualifies as PCM time. The work should represent actual qualifying disease-specific care management.
6. Double Counting Time
When patients receive multiple care-management or remote-monitoring services, make sure the same work and time are not improperly attributed to multiple codes.
How ChronicSync Can Help
PCM becomes harder to manage as specialists and care teams enroll more high-risk patients and need to track disease-specific care plans, monthly activity, staff responsibility, and qualifying time.
ChronicSync helps care teams organize longitudinal care-management workflows, maintain structured documentation, track patient activities, and improve visibility across monthly care programs.
Start your ChronicSync Free Pilot and explore a more organized approach to chronic care management.
Frequently Asked Questions
What are the four Principal Care Management CPT codes?
The primary PCM codes are CPT 99424, 99425, 99426, and 99427.
What is CPT 99424?
CPT 99424 represents the first 30 minutes of qualifying PCM services personally performed by a physician or other qualified healthcare professional during a calendar month.
What is CPT 99425?
CPT 99425 is an add-on code representing an additional 30 minutes of qualifying practitioner PCM services after the applicable base-code requirements are satisfied.
What is CPT 99426?
CPT 99426 represents the first 30 minutes of qualifying PCM services performed by clinical staff under the direction of a physician or other qualified healthcare professional during a calendar month.
What is CPT 99427?
CPT 99427 is the clinical-staff PCM add-on code for each additional 30 minutes when the applicable base-code requirements are satisfied.
Can PCM be billed for 20 minutes?
CMS states that PCM services of less than 30 minutes per calendar month cannot be billed.
How long must the principal condition be expected to last?
CMS describes PCM as focusing on a high-risk chronic condition expected to last at least three months.
Does PCM require a care plan?
Yes. CMS identifies creation of a disease-specific care plan as a required PCM element.
Sources
- CMS Medicare Learning Network: Chronic Care Management and Principal Care Management
- CMS: Principal Care Management Service Definitions
This article is for educational purposes only and does not constitute medical, legal, coding, reimbursement, or billing advice. CPT, Medicare, Medicare Administrative Contractor, and commercial-payer rules may change. Verify current requirements and the current CPT code set before submitting claims.