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Care ManagementOctober 14, 2026

Principal Care Management Explained: PCM Codes and Rules

Matteo

Updated October 2026. Written by Matteo Grassi, cofounder of HANA Health, trained in psychology.

Principal care management (PCM) is a Medicare service that pays practices to manage one high risk chronic condition between visits. The condition must be expected to last at least 3 months and put the patient at significant risk of hospitalization or decline. Practices report PCM monthly with CPT codes 99424, 99425, 99426 and 99427, once at least 30 minutes of qualifying time is documented. CMS created the service in 2020.

I come at this as a clinician first: the test for PCM isn't whether a patient is sick, it's whether one condition creates enough monthly work to deserve its own plan.

Key facts

What is principal care management (PCM)?

PCM is a monthly Medicare service for managing one serious chronic condition between appointments. CMS describes it as focused on a single high risk condition expected to last at least 3 months that places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death (CMS MLN909188). CMS finalized payment for it in the CY 2020 rule, first with Medicare specific G codes (Federal Register). Today practitioners report it with CPT codes 99424 through 99427.

Picture a patient with advanced heart failure. Between visits, that patient may need medication changes, specialist calls and regular check ins. Before PCM, much of that work went unpaid.

PCM also appears inside the advanced primary care management (APCM) bundle. CMS lists it next to CCM, transitional care management, interprofessional consultations and online digital visits as elements that APCM rolls together (CMS MLN909188). APCM doesn't require you to count minutes, so the minute rules below apply when you bill PCM on its own.

Who qualifies for PCM, and what should the condition look like?

A qualifying patient has one complex chronic condition that meets the CPT descriptor. CMS reproduces that descriptor in its Medicare Learning Network booklet, and it sets out five elements (CMS MLN909188, 2022 edition):

  1. The condition is expected to last at least 3 months.
  2. It places the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.
  3. It requires development, monitoring or revision of a disease specific care plan.
  4. It requires frequent adjustments to the medication regimen, or managing it is unusually complex because of comorbidities.
  5. It requires ongoing communication and care coordination between the relevant practitioners.

CMS describes criteria rather than a fixed diagnosis list, so your chart has to show how the condition meets them. A diagnosis code alone won't do that. Write a sentence or two on why this patient needs monthly management beyond office visits.

PCM can continue monthly as long as the patient needs it. CMS notes that after one year another initiating visit is required to keep going (CMS MLN909188).

Which PCM code do you bill: 99424, 99425, 99426 or 99427?

The code depends on who did the work and how long they spent in the calendar month. The descriptors split into two tracks:

  • 99424: the first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.
  • 99425: each additional 30 minutes of that personal time, reported as an add on to 99424.
  • 99426: the first 30 minutes of clinical staff time directed by the physician or other qualified health care professional, per calendar month.
  • 99427: each additional 30 minutes of clinical staff time, reported as an add on to 99426.

Here's a worked example for one patient with heart failure, using the staff track. The arithmetic is ours, built from the descriptors.

  1. Week one: a nurse spends 14 minutes on a medication review call and 6 minutes updating the disease specific care plan. Running total: 20 minutes.
  2. Week two: 9 minutes coordinating with the cardiology office. Running total: 29 minutes. That's still under 30, so nothing is billable yet.
  3. Week three: 7 minutes on a follow up call. Running total: 36 minutes. You can report 99426 once.
  4. Next month: staff logs 68 minutes. The first 30 minutes support 99426, the next 30 support one unit of 99427, and the last 8 minutes don't make a full block. Report 99426 and one unit of 99427.

Time spent can't be counted twice. As with CCM, minutes counted toward one billed service can't count toward another (CMS MLN909188). Ask your Medicare Administrative Contractor (MAC) about unit limits for the add on codes before you build a billing workflow around long months.

I'm leaving out dollar amounts on purpose. Rates vary by locality, so pull the current figure for each code from the CMS Physician Fee Schedule look up tool.

Can you bill PCM and CCM for the same patient?

Not by the same practitioner in the same month. CMS answered this directly in its CCM FAQs: CCM and PCM can't be billed by the same practitioner for the same patient in the same month, but a primary care practitioner can offer CCM while a specialist offers PCM, or the reverse, as long as the conditions being addressed are different (CMS CCM FAQs).

If both run at once, two care plans are required. The PCM plan only needs to be disease specific, while CCM needs a comprehensive plan. Here's a quick way to sort patients:

  • One dominant condition that needs its own monthly work: PCM may fit.
  • Two or more chronic conditions managed together by one practitioner: CCM usually fits better. Our CCM guide and CCM code guide cover that path.
  • Primary care bills CCM and a specialist manages a separate condition: both can bill if the conditions differ and each service has its own plan.

CMS's care management guidance also notes that other billing restrictions may apply if you take part in a CMS sponsored model or demonstration, so check your participation agreements before you add PCM.

What does PCM require before and while you bill it?

Four pieces have to be in place: an initiating visit when applicable, patient consent, a disease specific care plan, and documented time.

An ASHP guide to CCM and PCM summarizes the start up rules. New patients, or patients not seen within the prior year, need PCM initiated during a comprehensive visit such as a level 2 to 5 office visit, an Annual Wellness Visit or an Initial Preventive Physical Exam. That initiating visit isn't part of PCM and can be billed separately. Established patients seen within the past year can start without a separate visit, though consent should still be documented (ASHP, October 2024).

Consent can be written or verbal. Tell the patient the service is available, what cost sharing may apply, and that they can stop at any time, effective at the end of the calendar month. Our CCM consent and care plan guide walks through the same conversation, which carries over to PCM.

For time, log the date, the minutes and the activity every time, so an auditor can see 30 qualifying minutes tied to the one condition in the plan.

What this means for your practice

PCM is a narrow tool, and it works best when you use it on purpose. A few practical steps:

  • Pull a list of patients where one condition drives most of the between visit work, such as heart failure, uncontrolled diabetes or advanced COPD.
  • Check whether anyone in your group already bills CCM for the same patient that month. If the same practitioner would bill both, pick one.
  • Write the disease specific care plan first. If you can't state why the condition needs monthly management, the patient may not meet the descriptor.
  • Set a 30 minute alert in your tracking so staff know when the first billable threshold is reached.
  • Decide who owns consent and the annual initiating visit check, so it doesn't fall between the front desk and the clinical team.

The CY 2027 proposed rule, issued July 14, 2026, is worth watching (CMS fact sheet). Comments closed September 14, and the final rule usually arrives in early November. ACP's summary says CMS asked for feedback on the care management code family, including whether the codes are duplicative and how to simplify them (ACP summary). The contractor proposal that drew the most attention covers RPM and RTM, and it doesn't touch PCM, as we explain in our CY2027 contractor proposal explainer. Treat the rules above as current until a final rule says otherwise.

Care management only pays when patients actually engage. HANA Health works with practices on the between visit outreach these programs depend on, and you can read more on the care coordination page.

Frequently asked questions

Does Medicare publish a list of conditions that qualify for PCM?

CMS's booklet describes criteria rather than a fixed list. The condition has to be a single high risk chronic condition expected to last at least 3 months, so your documentation has to show how it meets them.

Can I bill the initiating visit separately from PCM?

Yes, when a visit is required. The initiating visit isn't part of the PCM service, and its time can't count toward your 30 minutes (ASHP, October 2024).

Does PCM stop after one year?

No, but CMS requires another initiating visit after one year to continue. PCM can be provided monthly for as long as the patient needs it.

How is PCM different from APCM?

PCM is time based. You need at least 30 minutes in a calendar month. APCM is a bundled monthly service with codes G0556, G0557 and G0558, and CMS says it doesn't require you to count minutes (CMS MLN909188).

Sources

  1. Centers for Medicare and Medicaid Services, Medicare Learning Network, Chronic Care Management Services (MLN909188), June 2025: https://www.cms.gov/files/document/chroniccaremanagement.pdf
  2. Centers for Medicare and Medicaid Services, Medicare Learning Network, Chronic Care Management Services (MLN909188), March 2022 edition: https://www.marc.org/sites/default/files/2022-10/CMS-MLN-Chronic-Care-Management.pdf
  3. Centers for Medicare and Medicaid Services, Frequently Asked Questions About Practitioner Billing for Chronic Care Management Services, updated August 2022: https://www.cms.gov/files/document/chronic-care-management-faqs.pdf
  4. Federal Register, CY 2020 Revisions to Payment Policies Under the Physician Fee Schedule final rule, November 15, 2019: https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other
  5. Centers for Medicare and Medicaid Services, Calendar Year 2027 Medicare Physician Fee Schedule Proposed Rule fact sheet, July 14, 2026: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule
  6. American College of Physicians, Summary of the CY 2027 Physician Fee Schedule Proposed Rule, 2026: https://www.acponline.org/sites/default/files/documents/advocacy/where_we_stand/assets/cy_27_pfs_proposed_rule_summary_2026.pdf
  7. American Society of Health System Pharmacists, FAQ: Chronic Care Management and Principal Care Management, October 2024: https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/chronic-care-management-faq.pdf
  8. Centers for Medicare and Medicaid Services, Physician Fee Schedule: https://www.cms.gov/medicare/payment/fee-schedules/physician

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill.

If you want to talk through how your practice runs care management between visits, book a discovery call with Matteo.