PCM Billing: Principal Care Management Codes and 2026 Rates

Mukesh MakwanaFounder & CEO · Hands-on medical billing & RCM across 11 specialties · Reviewed November 1, 2026

Principal care management (PCM) is monthly care management for one high-risk chronic condition expected to last at least 3 months. Medicare pays for it under CPT codes 99424 and 99425 when the practitioner does the work personally, and 99426 and 99427 when clinical staff do it. At least 30 minutes in the calendar month is required. The 2026 national non-facility rate is $87.51 for 99424 and $67.80 for 99426, before cost sharing and geographic adjustment.

Want PCM running in your practice?

If you are a specialist, practice owner or office manager whose team manages patients with one serious condition between visits, that time may be billable. Let us know and we will set up the billing side of PCM for your practice: which patients to review, consent wording, a monthly time log, the right codes and the claim process. Your clinicians keep caring for the patients.

PCM billing codes and 2026 national Medicare rates

Each amount below is the code's total relative value units in the CMS 2026 relative value file times the 2026 conversion factor of $33.4009. To see your locality's amount, use the CMS Physician Fee Schedule Look-Up Tool.

Add-on codes (marked +) go on the claim with their base code only. Medicare's Medically Unlikely Edits for the fourth quarter of 2026 set 2 units per day for both 99425 and 99427.

Worked example: a cardiologist personally spends 65 documented minutes in one month managing a patient's unstable heart failure. That supports 99424 plus one unit of 99425, a national office total of $148.97 before adjustment. If the same doctor had logged 25 minutes, nothing would be billable: the CMS booklet says you cannot bill PCM for less than 30 minutes per calendar month.

NP and CNS rate: 42 CFR 414.56 limits Medicare's allowed amount for nurse practitioners and clinical nurse specialists to 85 percent of the physician fee schedule amount.

Which patients qualify for PCM

CMS describes the target as a single, high-risk chronic 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. When CMS created the service in its 2020 Physician Fee Schedule final rule (84 FR 62692), it said a qualifying condition is typically expected to last between 3 months and 1 year or until death, and may have led to a recent hospitalization. It also expected most cases to begin with an exacerbation or hospitalization that calls for disease-specific management, with the goal of stabilizing the patient and returning overall care to primary care.

The patient may have other conditions. PCM covers only the one condition being managed, and the primary care practitioner keeps managing the rest.

Who can bill PCM, and who pays

CMS placed no restriction on which specialties can bill PCM, but it expected most claims to come from specialists focused on one complex condition. A primary care practitioner can also bill it when the patient has only one complex chronic condition overseen by that practitioner. A patient can receive PCM from more than one clinician if more than one condition worsens at the same time.

Clinical staff time counts toward 99426 and 99427 only when Medicare's incident-to rules at 42 CFR 410.26 are met. In the 2020 rule, CMS added its original clinical-staff PCM code to the designated care management services allowed under general supervision. The current list is published each year with the fee schedule addenda, so confirm the current codes there.

• Original Medicare: bill Part B, and collect the patient's applicable cost sharing. Explain this when you get consent, since CMS specifically wants patients told what PCM is and what they may owe.
• Other payers: Medicare Advantage, Medicaid and commercial plans decide their own coverage and pay their own rates. Check before starting, because this page's dollar figures apply to Original Medicare only.

Where to bill PCM

A physician group sends the claim to its Medicare Administrative Contractor as a professional claim. PCM has both facility and non-facility amounts, and the place of service decides which applies. CMS's published place-of-service answer is written for CCM: report where the billing practitioner would ordinarily provide face-to-face care. Because CMS modeled PCM on CCM, use the same approach, and confirm with your MAC if your patients are seen in more than one setting.

RHCs and FQHCs follow a different route. The CMS manual update ended combined reporting under G0511 from January 1, 2025, so they report 99424 or 99426 and add-ons directly. Both the RHC and FQHC booklets list these PCM codes, paid at the national non-facility rate.

PCM vs CCM: requirements and reimbursement

CMS applied the chronic care management framework to PCM with changes made for single-condition care:

Three more items carry over from the 2020 rule:

• Initiating visit: required before PCM begins, and the booklet requires another initial visit after 1 year to continue services.
• Consent: document it in the medical record, covering the service and any cost sharing.
• Certified EHR: CMS kept this as an element of PCM.

When PCM cannot be billed

• With CCM: the CMS FAQ says the same practitioner cannot bill both for one patient in a month. A primary care practitioner can bill CCM while a specialist bills PCM if the conditions differ, with two care plans.
• With other care management: CMS said PCM should not be furnished with other care management services by the same practitioner for the same patient.
• With consults: CMS also said PCM should not run at the same time as interprofessional consultations for the same condition by the same practitioner.
• With APCM: advanced primary care management codes G0556 to G0558 bundle PCM, so choose monthly bundled billing or time-based PCM, not both for the same work.

Specialty practices should compare PCM with their other monthly work, including remote monitoring and cardiology billing generally. Our denial management services can work PCM claims denied for missing time or consent.

Set up PCM for your practice

Tell us your specialty, your EHR and the conditions you manage most. Sterling Global Solution LLC will set up PCM billing for your practice and answer your questions. If you just need help with a claim or a question, please contact us.

Frequently asked questions

Sources

Centers for Medicare & Medicaid Services, MLN909188, June 2025 (PCM and APCM sections), and CCM billing FAQ.
Federal Register, CY 2020 Physician Fee Schedule final rule, 84 FR 62692 to 62697: creation and scope of PCM.
Centers for Medicare & Medicaid Services, CY 2026 PFS Relative Value File RVU26D (October release, non-QP conversion factor $33.4009); rates calculated by Sterling Global Solution LLC as total RVU times conversion factor.
Centers for Medicare & Medicaid Services, Medicare NCCI Medically Unlikely Edits, fourth quarter 2026; Benefit Policy Manual update, Rev. 13600; MLN006398; MLN006397. Code of Federal Regulations, 42 CFR 414.56.

CPT® is a registered trademark of the American Medical Association. Rates are Original Medicare national amounts for 2026, before geographic adjustment and payment reductions. Other payers set their own rates. Not legal advice. How we verify this guidance.

Related reading

• CCM billing. For two or more chronic conditions: 99490 and related codes.
• Cardiology billing services. Specialty billing including monthly care.
• Denial management services. Working every denial before its deadline.
• Contact Sterling Global Solution LLC. Ask us about your PCM program or claims.