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Patients spend most of their time outside the hospital, out in the world, living their lives, and how they manage a serious condition during those weeks and months largely determines how well they do. Keeping patients connected to their care team during that time is the heart of what we do. It is also, increasingly, something Medicare is willing to pay for.
Care management is often described in terms of the patient with a long list of chronic illnesses. But many of the patients who most need ongoing, between-visit attention are defined by one serious condition, a knee or hip failing from advanced osteoarthritis, a spine steadily deteriorating, a major joint working through recovery. For those patients, Medicare offers a specific pathway: Principal Care Management (PCM). It is worth understanding, because for many care teams it describes work they are already doing.
What is Principal Care Management?
PCM is a set of time-based Medicare services for managing a patient with a single, complex chronic condition. It is a close cousin of the more familiar Chronic Care Management (CCM), with one defining difference. CCM is intended for patients with two or more chronic conditions expected to last at least 12 months. PCM was created for the patient whose care is driven by one high-risk condition. As the American Academy of Professional Coders (AAPC) explains, a single diagnosis does not qualify a patient for CCM, but that same patient may qualify for PCM instead.
For orthopedic and musculoskeletal (MSK) teams, that difference is meaningful. A patient's care is often organized around one dominant problem rather than a long list of comorbidities, which is exactly the situation PCM was built to address. It gives the care team a defined way to be recognized for managing that condition in the stretches between office visits.
The PCM Codes, In Plain Terms
Effective in 2022, the CPT code set introduced four PCM codes that replaced two earlier HCPCS codes (G2064 and G2065). According to AAPC, they are organized by who performs the work and how much time is spent in a calendar month:
- 99424 — principal care management for a single high-risk disease, first 30 minutes provided personally by a physician or other qualified health care professional (QHCP), per calendar month.
- +99425 — each additional 30 minutes provided personally by the physician or QHCP (an add-on code).
- 99426 — first 30 minutes of clinical staff time directed by a physician or other QHCP, per calendar month.
- +99427 — each additional 30 minutes of clinical staff time (an add-on code).
A handful of rules govern how the codes are used. The base codes can be billed only once per calendar month, and neither the base nor the add-on codes are billable unless at least 30 minutes are documented. A provider cannot bill PCM and another care management service for the same patient in the same month. And the clinical-staff codes (99426 and +99427) require direct physician or QHCP supervision, which CMS defines as the physician being immediately available, though not necessarily in the same room.
What A PCM Claim Has To Show
Time alone is not enough. AAPC notes that CPT requires the record to document four elements, and together they describe precisely the kind of patient a connected care team is built to follow:
- Patient consent must be obtained, written or verbal, and documented in the medical record prior to the beginning of PCM services, including an explanation of service, shared costs, and that patients can stop PCM services at any time.
- A single complex chronic condition, expected to last at least three months, placing the patient at significant risk of hospitalization, acute exacerbation or decompensation, functional decline, or death.
- A disease-specific care plan that the condition requires the team to develop, monitor, or revise.
- Complexity of management, whether from frequent medication adjustments or from comorbidities that make the condition unusually complex to manage.
- Ongoing communication and care coordination among the practitioners furnishing the patient's care.
Importantly, the time that counts toward PCM does not have to be face-to-face. Per AAPC, establishing and revising the care plan, coordinating care, and educating the patient about their condition, care plan, and prognosis all count. That is the connective tissue of good longitudinal care, the work that happens between appointments and has historically gone unrewarded.
A Caveat That Matters For Surgical Teams: The Global Period
For orthopedic and other surgical programs, one restriction deserves particular attention. PCM cannot be billed during a procedure's global surgical period. Under Medicare's global surgery package, the pre-operative visit, the procedure, and the routine post-operative care that follows are bundled into a single payment, so the condition-management work done inside that window is already accounted for and cannot be separately reported as PCM.
PCM also cannot be billed concurrently with several other services for the same patient in the same month, including Chronic Care Management, behavioral health integration, and the monthly capitated payment for ESRD-related care. However, remote patient monitoring (RPM) and remote therapeutic monitoring (RTM) may be billed alongside PCM by the same practitioner, as long as the same time is not counted twice and only either RPM or RTM are billed, not both.
The practical implication is that PCM fits best where care is longitudinal and not folded into a surgical bundle, for example managing severe osteoarthritis before a decision to operate, managing a patient nonoperatively, or picking up recovery after the global period closes.
Why PCM and Superior Care Go Hand in Hand
Read the requirements together and a familiar picture emerges: a defined condition, a written and evolving care plan, monitoring over time, and coordination among the people responsible for the patient. For teams that have already extended themselves into the home, this is not new work. It is the shape of the work they do every day.
It is also the model our partners run on Force. Care on our platform begins with thoughtful, physician-prescribed pathways, condition- and procedure-specific care plans delivered through video-based education, structured check-ins, and remote monitoring across the full episode of care. Having guided patients through their episodes of care for more than 15 years, we have seen that patients stay engaged when the plan comes from a trusted source, their own care team, rather than a service bolted on from the outside. When the team owns that relationship, the disease-specific care plan already exists, the monitoring is already happening, and the coordination among practitioners is already captured, the very elements PCM asks a claim to demonstrate.
The hard part of any time-based care management service is rarely the clinical work; it is capturing and documenting it. A platform that records engagement, logs care-plan changes, and surfaces which patients need attention turns scattered effort into a clear, defensible record, which is what makes a service like PCM both billable and audit-ready.
A Quiet Opportunity Worth A Second Look
Care management codes rarely command attention the way a new payment model does. But together they reflect a steady, deliberate shift toward paying clinicians to keep patients well over time rather than only treating them in the moment. PCM is a small but telling piece of that shift, a recognition that a single serious condition, managed well between visits, has real value.
For orthopedic and MSK teams, the relevant population is sizable. A patient managing severe hip or knee osteoarthritis without surgery, or working through recovery after a major procedure, often has exactly one condition organizing their care. Rather than a new program to stand up, many teams may find PCM simply names care they are already delivering and have not been capturing.
How To Evaluate if PCM Works For You
For orthopedic and specialty care teams, and the quality and value-based-care leaders who support them, a few implications stand out:
- Look at your single-condition patients: Patients who do not qualify for CCM because they have only one dominant chronic condition may still qualify for PCM. That group is easy to overlook.
- Build the documentation into the workflow: PCM rests on a disease-specific care plan, monitoring, coordination, and time. Capturing those as a natural part of care, not a separate charting task, is what makes the service defensible.
- Mind the global period and concurrent-billing limits: PCM cannot be billed during a procedure's global surgical period or concurrently with services like CCM for the same patient in the same month. Map where PCM fits around your surgical episodes.
- Keep the relationship inside the care team: PCM and its supervision requirements reward care owned by the clinicians accountable for the patient, not outsourced to a detached vendor.
- Confirm the current-year specifics: Reimbursement amounts, supervision rules, and code details are set by CMS and updated annually. Verify them with your billing and compliance teams before submitting claims.
Principal Care Management will not transform a service line on its own. But for teams already managing high-risk conditions across the episode of care, it is a well-aligned way to be recognized for work that improves outcomes and, done right, adds no cost. Continuous, condition-specific care, owned by the patient's own team, is exactly the model we build for.
To learn more about how leading institutions structure condition-specific, team-owned care management and patient engagement programs, reach out to the Force team through the form below:
