A three-physician cardiology group asked us to look at why their nurse was so busy and their revenue for the nurse's work was zero. She spent most of every afternoon on the phone with heart failure patients: weight checks, diuretic adjustments relayed from the physician, refills, pharmacy calls, and the occasional trip to the emergency department averted. None of that time touched a claim. The group had heard of chronic care management and assumed it belonged to primary care. They were half right, and the half they were missing was principal care management.
Principal care management, billed with CPT codes 99424 to 99427, pays for exactly the work that nurse was doing: managing one serious condition between visits. It has been in the CPT book since 2022, when it replaced the temporary HCPCS codes G2064 and G2065 that Medicare introduced in 2020. Four years on, we still find that most specialty practices either do not know it exists or believe they cannot bill it because the primary care office already bills chronic care management for the same patient. Both beliefs cost money and, more to the point, they leave real care coordination unpaid.
A glossary line. Care management codes pay for non-face-to-face work done during a calendar month: phone calls, medication management, coordination with other clinicians, care plan updates. Chronic care management (CCM) is the version for patients with two or more chronic conditions. Principal care management (PCM) is the version for a single complex condition, and it was designed with specialists in mind.
Key takeaways
- PCM requires one complex chronic condition expected to last at least three months that puts the patient at significant risk of hospitalization, decompensation, functional decline or death.
- 99424 and 99425 cover time spent personally by the physician or qualified health professional; 99426 and 99427 cover clinical staff time under their direction, and the two tracks are not combined.
- Each code needs a full 30 minutes; 45 minutes of nurse time in a month is 99426 alone, not 99426 plus 99427.
- The same practitioner cannot bill PCM and CCM for the same patient in the same month, but a specialist billing PCM and a primary care physician billing CCM for the same patient is allowed.
- Consent, an initiating visit for new patients, a disease-specific care plan and a time log are the four documentation pieces auditors ask for first.
What principal care management 99424 to 99427 actually requires
The CPT descriptors set out the conditions, and the Medicare Physician Fee Schedule adopts them. The patient must have one complex chronic condition expected to last at least three months, and that condition must place the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death. The condition must require the development, monitoring or revision of a disease-specific care plan. It must require frequent adjustments to the medication regimen, or its management must be unusually complex because of comorbidities. And there must be ongoing communication and care coordination between the relevant practitioners caring for the patient.
Heart failure with recent diuretic titration, COPD with frequent exacerbations, a rheumatologic condition on a biologic with monitoring labs, uncontrolled epilepsy, advanced chronic kidney disease, and an active cancer under treatment all fit the description when the documentation shows the risk and the ongoing management. Stable, well-controlled hypertension does not, even though it is chronic. The word "complex" is in the descriptor on purpose.
The four codes split by who does the work and how much time they spend. 99424 is the first 30 minutes per calendar month of PCM services provided personally by a physician or other qualified health care professional, such as a nurse practitioner or physician assistant. 99425 is each additional 30 minutes of that same personal time. 99426 is the first 30 minutes per month of PCM provided by clinical staff, under the direction of the physician or QHP. 99427 is each additional 30 minutes of clinical staff time. You report one track or the other in a given month, based on who did the work, and you do not add the physician's 15 minutes to the nurse's 20 minutes to reach a threshold.
How PCM differs from chronic care management
The practical differences matter when a practice decides which program to build. The table below compares the two families as they stand in 2026.
| Element | Principal care management | Chronic care management |
|---|---|---|
| Conditions required | One complex chronic condition | Two or more chronic conditions expected to last 12 months or until death |
| Physician or QHP codes | 99424 first 30 minutes, 99425 each additional 30 | 99491 first 30 minutes, 99437 each additional 30 |
| Clinical staff codes | 99426 first 30 minutes, 99427 each additional 30 | 99490 first 20 minutes, 99439 each additional 20; complex CCM 99487 first 60 minutes with moderate or high decision making, 99489 each additional 30 |
| Care plan | Disease-specific plan for the one condition | Comprehensive plan across all conditions |
| Typical biller | Specialist managing the condition | Primary care practice |
| Same patient, same month | PCM by a specialist and CCM by a different practitioner is allowed; same practitioner cannot bill both | Same rule from the other side |
| Patient consent | Required, documented, once, and can be verbal | Same |
| Cost sharing | Part B coinsurance applies | Same |
Since January 1, 2025, Medicare has also paid the advanced primary care management codes G0556, G0557 and G0558, which bundle care management into a monthly payment with no time requirement. Those codes are aimed at primary care and cannot be billed by the same practitioner in the same month as CCM or PCM for the same patient. For a specialist, that is not a conflict; the primary care office can bill APCM and the cardiologist can still bill PCM for the heart failure work. Our closing gaps in care team helps practices sort out which practitioner owns which program for shared patients, because the mapping is where most of the confusion sits.
A month of billable work, with numbers
Return to the cardiology nurse. In one month she logs the following for a fictional 71-year-old patient with heart failure and reduced ejection fraction: a 12-minute call on the 3rd to review daily weights and relay a furosemide increase ordered by the cardiologist, an 8-minute call on the 7th to confirm the change and check symptoms, 10 minutes on the 15th coordinating a potassium level with the lab and the primary care office, and 9 minutes on the 24th documenting a care plan update after the level came back. That is 39 minutes of clinical staff time in the calendar month. The claim is 99426, one unit. It is not 99426 plus 99427, because the second 30-minute block was not completed.
The cardiologist separately spent 6 minutes reviewing the weight log and deciding on the dose change, and 5 minutes on a message to the primary care physician. That 11 minutes of physician time does not reach 99424, and it cannot be added to the nurse's 39 minutes. It is simply part of the physician's supervision of the program. The following month, if the physician personally spends 32 minutes on a medication overhaul and the nurse spends 15 minutes, the claim is 99424 for the physician time; the nurse's 15 minutes goes unbilled.
Two rules keep this honest. First, time counted toward PCM cannot also be counted toward any other service, such as a transitional care management episode or a face-to-face visit on the same day. Second, only clinical staff time counts for 99426 and 99427; a front desk scheduler calling to book an echo is not clinical staff time. We ask practices to define, in writing, which roles count before the first claim goes out.
Documentation that survives an audit
Medicare contractors reviewing care management claims ask for a predictable set of items, and we have the practice build the chart to answer them without a hunt. The first is consent: a note showing the patient agreed to PCM, was told that only one practitioner can bill PCM for the same condition, that cost sharing applies, and that the patient can stop at any time. Verbal consent is acceptable when documented. The second is the initiating visit: for a new patient, or one not seen in the past year, a face-to-face visit before PCM begins, which can be a standard E/M visit. The third is the disease-specific care plan, in the record and shared with the patient, listing the problem, goals, medications, monitoring, and who does what. The fourth is the time log, showing date, minutes, who performed the work, and what was done.
The weak point in most practices is the time log. Staff remember the calls and forget to record them, or they record "phone call" with no minutes. We set a rule that any PCM activity is logged before the next task starts, with a template that forces a minute count and a one-line description. It sounds fussy. It is also the difference between a claim you can defend and one you refund.
Which specialists should build a PCM program
Honestly, not every practice should. A dermatology group whose patients need little between-visit management will spend more setting up the workflow than it collects. The specialties where PCM pays for itself have three features: a chronic condition with real decompensation risk, medication regimens that change often, and staff already doing the coordination for free. Cardiology, pulmonology, nephrology, rheumatology, neurology for seizure and movement disorders, endocrinology for insulin-dependent diabetes, and oncology fit. Orthopedics after a joint replacement generally does not, because the condition is not chronic in the required sense.
The setup work is about a month. Pick the condition or conditions, write the care plan template, define the eligible roles, build the time log into the EHR, script the consent conversation for the visit, and set the billing rule that the claim goes out on the first business day after the calendar month closes. Payment rates for 99424 to 99427 are on the Medicare Physician Fee Schedule and vary by locality; commercial payers set their own, and some do not cover PCM at all, so check the top five before assuming the program applies to every patient.
Questions we hear
Can two specialists bill PCM for the same patient in the same month?
Yes, if each is managing a different complex condition and each meets the requirements independently. A nephrologist billing PCM for chronic kidney disease and a cardiologist billing PCM for heart failure in the same month is allowed. Two practitioners billing PCM for the same condition is not, and Medicare will pay the first claim and deny the second.
Does the patient need to be told about cost sharing every month?
No. Consent is obtained once, before services begin, and stays in effect until the patient withdraws it or changes practitioners. Document it once, well. If the patient later has a complaint about a coinsurance bill, that consent note is what you point to.
Can we bill PCM in a month when the patient also had an office visit?
Yes. The office visit is billed with its E/M code and the PCM code is billed for the non-face-to-face time in the rest of the month. The visit time itself does not count toward the PCM threshold, and the PCM minutes cannot include the visit. Keep the two clearly separated in the log.
What to do this week
- List the ten patients your clinical staff called most often last month and identify the single condition driving those calls.
- Check whether any of those patients had a face-to-face visit with the practice in the past 12 months, and schedule one for those who did not.
- Draft a one-page disease-specific care plan template for your highest-volume complex condition.
- Build a time log in the EHR with date, minutes, staff role and activity, and train staff to log before starting the next task.
- Look up 99424 to 99427 on the Medicare fee schedule for your locality and ask your top five commercial payers whether they cover PCM. If you want help mapping who bills what for shared patients, book a call with us.
