What does Principal Care Management pay in 2026?
| Code | What it covers | CY2026 national non-facility |
|---|---|---|
| 99424 | practitioner personally, first 30 min | $87.51 |
| 99425 | practitioner personally, each added 30 min | $61.46 |
| 99426 | clinical staff, first 30 min | $67.80 |
| 99427 | clinical staff, each added 30 min, max 2 units | $54.11 |
National averages from our verified CY2026 fee-schedule config (source: CMS Physician Fee Schedule). Actual payment varies by locality, payer, and site of service.
Who can bill it?
Physicians and NP/PA/CNS/CNM practitioners — commonly the specialist who owns the qualifying condition.
Clinical staff furnish minutes under the billing practitioner's direction on the 99426/99427 pair; the practitioner's own time bills 99424/99425.
One practitioner bills PCM for a given condition in a given month. Two different practitioners CAN each bill PCM for the same patient in the same month — for different conditions.
What are the minute thresholds?
- 30 minutes of clinical-staff time in the calendar month opens 99426.
- Each added 30 minutes bills a 99427 unit, capped at 2 (CMS MUE, clinically appealable above with documentation — but 2 is the default).
- Practitioner personal time uses the parallel 99424/99425 pair in 30-minute blocks.
- Minutes count once — time claimed by another billed service is excluded.
What has to be in place first?
- One qualifying condition
- A single complex chronic condition expected to last at least 3 months that places the patient at significant risk — with a disease-specific care plan for it.
- Consent with the single-biller disclosure
- Same consent structure as CCM — documented, and the patient told only one practitioner bills the program per condition per month.
- Enrollment and clinical attestation
- Program enrollment plus the practitioner's clinical-eligibility attestation — a judgment call the practitioner owns, not an ICD lookup.
- A complete claim identity
- Rendering NPI and practitioner type on file.
What gets claims denied?
- Same practitioner running CCM and PCM together
- The same practitioner cannot bill CCM and PCM for the same patient in the same month — the condition either lives in the comprehensive program or the principal one.
- APCM exclusivity
- A confirmed APCM bundle for the patient-month blocks PCM, like CCM and TCM.
- Add-on units past the cap
- More than 2 units of 99427 exceeds the CMS MUE default and denies without documented, appealable justification.
- QMB balance-billing
- Same as every care-management family: QMB patients cannot be billed Medicare cost-sharing.
- Assuming commercial parity
- Commercial adoption of PCM lags CCM's. Verify the payer has loaded 99424–99427 before projecting.
What could this look like for your panel?
Estimates only, not billing advice. Actual Medicare reimbursement varies by region, payer, and year. Figures approximate CY2026 national non-facility averages from our verified fee-schedule config.
Frequently asked questions
- What's the difference between PCM and CCM?
- The condition count. CCM requires two or more chronic conditions and manages the whole picture; PCM requires exactly one serious, high-risk condition managed as its own program — typically by the specialist who owns it.
- Can a cardiologist and an endocrinologist both bill PCM for one patient?
- Yes — in the same month, each for their own condition. What's barred is two practitioners billing for the same condition, or one practitioner stacking PCM on CCM for the same patient.
- Which code pair do I use — 99424 or 99426?
- Whose time it was. The practitioner's own time bills 99424/99425; clinical-staff time under the practitioner's direction bills 99426/99427.
- Is there an initiating-visit requirement?
- PCM follows the CCM-style structure: patients new to the practice need a qualifying visit before the program starts, and consent plus enrollment come before the first claim.
This page is general information, not billing, coding, or legal advice. Verify current requirements with the relevant payer before billing. Mallowa helps practices capture and document coordination time and generates claim-ready superbills; it does not submit claims or determine eligibility.