Principal Care Management

What it is

Principal Care Management (PCM) is a Medicare benefit for patients with a single complex chronic condition that places them at risk of decompensation, acute exacerbation, or functional decline. PCM differs from CCM in that PCM focuses on the management of one condition, often by a specialist — a cardiology HF panel, a nephrology CKD panel, an endocrinology T2DM panel.

Billed monthly in 30-minute tiers.

Who qualifies

• Patient has one complex chronic condition expected to last ≥ 3 months, with a high risk of decompensation, hospitalization, or functional decline.
• Care is provided by a single practitioner or care team focused on that condition.
• Patient consent on file.
• Disease-specific care plan exists and is accessible to the patient + team.
• May be billed concurrently with CCM by a different practitioner (e.g., specialist bills PCM while PCP bills CCM); cannot be billed by the same practitioner for the same condition.
• Not concurrently allowed with APCM.

Codes & when to bill them

Each billable code, with the requirements that must be on file to bill it.

• 99426First 30 minutes of clinical staff time directed by a physician or QHCP, per calendar month — clinical staff PCM.
  Requirements≥ 30 minutes total clinical staff time; care plan on file; consent on file.
• 99427Each additional 30 minutes of clinical staff time (use with 99426). Max 2 add-ons per month.
  RequirementsAdd-on to 99426.
• 99424First 30 minutes of PCM personally performed by the billing physician or QHCP.
  RequirementsPractitioner's own time only. Cannot combine with 99426 or 99425 in the same month.
• 99425Each additional 30 minutes personally performed (use with 99424). Max 2 add-ons.
  RequirementsAdd-on to 99424.

Documentation required every cycle

Each calendar month must show:

1. Total clinical staff or practitioner time spent on PCM (rounded to the minute).
2. Condition-specific care plan documenting the focused intervention.
3. Care coordination with the patient's PCP and other treating clinicians.
4. Patient consent on file with version, date, and capture method.
5. Practitioner sign-off at month close.

What's new in CY 2026

CY 2026 retains the PCM code set. PCM may be concurrent with CCM only when billed by different practitioners; the same practitioner cannot bill both for the same patient in the same month for overlapping condition management.

Built-in patient consentWillowbridge exclusive

Every program ships with compliant, CY-2026 patient consent language — read verbatim into the in-app consent capture flow, captured with date + modality, and version-pinned to each claim, so the consent on file always matches the consent that was billed. No more chasing signatures or re-papering when the rule changes.