How to bill Principal Care Management codes when 2 specialists are involved

Jonathan Rubenstein, MD (shown here), and Mark Painter write, "There are 4 Current Procedural Terminology (CPT) codes associated with PCM."

When billing Principal Care Management (PCM) codes, what is the appropriate billing when a patient’s care is split between 2 providers from different specialties? An example would be a patient with advanced prostate or bladder cancer, with the urologist monitoring urinary issues and a medical oncologist monitoring chemotherapy-related issues, but both working for the same hospital or organization. Who would bill and get credit for the PCM code?

Mark Painter (shown here) and Jonathan Rubenstein, MD, write, "Based on the diagnosis of advanced prostate cancer or bladder cancer, it is possible that your urologist has developed the plan of care that includes chemotherapy as the primary care provider for the disease state."

PCM codes were created because specialty care practitioners often treat patients with a single high-risk disease and do not meet criteria for reporting other types of care services requiring management of multiple conditions. A serious, chronic condition is defined by a patient having a diagnosis that is expected to last at least 3 months to a year or until death and that:

• May have led to recent hospitalization or has significant potential to do so,

• Places patient at significant risk of death, or

• Must be actively managed to prevent acute exacerbation, decompensation, or functional decline

PCM codes require the practitioner to develop a disease-specific care plan, to obtain a patient’s verbal or written consent, and to educate the patient on PCM. Patients require uninterrupted (24 h/d, 7 d/wk) access to a dedicated care team member. A minimum of 30 min/mo is needed to submit a claim for reimbursement.

There are 4 Current Procedural Terminology (CPT) codes associated with PCM, based upon the first 30 minutes vs additional 30 minutes per calendar month of care, and based upon the work being performed by a physician or other qualified health care professional who can bill for such services or by clinical staff. The codes are as follows:

• 99424 (Principal care management services, for a single high-risk disease, with the following required elements: 1 complex chronic condition expected to last at least 3 months and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death; the condition requires development, monitoring, or revision of disease-specific care plan; the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional per calendar month)

• 99425 (Principal care management services, for a single high-risk disease… each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month [list separately in addition to code for primary procedure])

• 99426 (Principal care management services, for a single high-risk disease… first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)

• 99427 (Principal care management services, for a single high-risk disease... each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month [list separately in addition to code for primary procedure])

The case described above states that the urologist is following the patient for urinary issues whereas the oncologist is monitoring chemotherapy-related issues. Even when it comes to monitoring patients for chemotherapy, it is important that one meets these criteria. Based on your question, it seems that the PCM would be of the patient’s cancer, with urinary and chemotherapy possibly being part of the care plan.

Based on the diagnosis of advanced prostate cancer or bladder cancer, it is possible that your urologist has developed the plan of care that includes chemotherapy as the primary care provider for the disease state. As noted in the description, the billing physician must be the one who provides the development, monitoring, and revision of the care plan and is responsible for adjustment of care either directly or through coordination with other health care professionals. Documentation will need to support these aspects of the services provided, including any coordination of care.

If, on the other hand, it is possible that the primary care of the prostate or bladder cancer is primarily under the oncologist due to the disease state, it may be more appropriate for the oncologist to be the primary manager of the disease state even though your urologist did so previously.

One person should be designated the primary caretaker of the patient’s cancer and underlying disease, and whomever is specifically responsible for overall care of the patient should report the codes. Reporting of these services should be coordinated between the physicians.