One condition is enough. It just has to be serious.

One complex chronic condition expected to last at least three months, serious enough to risk hospitalisation or decline. The count is what separates this from chronic care management: CCM asks for two or more conditions, PCM asks for one that is serious enough to need its own care plan.

Thirty minutes of clinical staff time in a calendar month, directed at that single condition, against a disease-specific care plan the patient has consented to.

The gate and the focus. CCM needs two or more chronic conditions and the care plan covers the whole patient. PCM needs one complex condition and the thirty minutes stay on that condition. A practice that has read the CCM page and found its sickest single-condition patients ineligible is looking at the wrong programme, not the wrong patient.

99426 if clinical staff did the thirty minutes, 99424 if the physician or another qualified professional did. They are mutually exclusive in a month, so it is one or the other, never both. Note that this numbering is the reverse of CCM's, where 99490 is the clinical staff code and 99491 is the physician code.

99426 is CY2026 $67.80 national non-facility, before geographic adjustment, for one patient in one calendar month. It is not what the practice collects: sequestration and the standard Part B patient coinsurance both come off, and the amount varies by locality. On the same basis the physician track, 99424, is $87.51, and each further thirty minutes is 99427 ($54.11) for staff time or 99425 ($61.46) for the practitioner's own.

The same practitioner cannot bill PCM and CCM, or PCM and APCM, for a patient in the same month, though a specialist can bill PCM for a different condition while the primary care practice bills CCM. 99424 and 99426 are also one or the other: a month is either the physician track or the clinical staff track, never both.

It makes the monthly contact and keeps it on the one condition rather than drifting across the whole chart, asks what your clinicians scoped, in 30+ languages, and writes it up the same day for your clinician to review. Your clinicians own the care plan and every decision on it, and nothing bills until a person on your team approves the note.

CMS uses the CPT definition rather than a list. One complex chronic condition expected to last at least three months, that puts the patient at significant risk of hospitalisation, acute exacerbation, functional decline or death, and that needs a disease-specific care plan developed, monitored or revised. It also needs frequent medication adjustments or management made unusually complex by other conditions. It is a clinical judgement your practitioner documents.

The same way as for chronic care management: verbally or in writing, before the service starts, documented in the patient's record.

Yes. PCM starts at an initiating visit with the billing practitioner, and CMS's guidance asks for another one after a year to keep the service going.

Physicians, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives. On 99426 the thirty minutes are clinical staff time under general supervision; on 99424 they are the practitioner's own. Only clinical staff time counts, so HANA's call time never does.

As proposed in July 2026, nothing for PCM. The proposal that would require staff employed by the practice covers remote monitoring only. CMS asked for comments on supervision across care management, so this is one to re-check when the final rule lands, expected around November 2026.