Medicaid

Georgia Medicare Principal Care Management PCM 2026

The Medicare Principal Care Management benefit gives every Georgia Medicare beneficiary with a single complex chronic condition expected to last at least three months — a condition that places the

Brevy Care Team

· 34 min read

By Brevy Care Team · Last verified May 14, 2026

The Medicare Principal Care Management benefit gives every Georgia Medicare beneficiary with a single complex chronic condition expected to last at least three months — a condition that places the beneficiary at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death — the right to receive structured single-condition disease management services from a designated managing practitioner who may be a primary care physician but is commonly a specialist who manages the specific chronic condition. PCM is billed under CPT 99424 (physician-personally-furnished PCM, 30+ minutes per calendar month), CPT 99425 (physician-personally-furnished PCM add-on, each additional 30 minutes), CPT 99426 (clinical staff PCM, 30+ minutes per calendar month directed by physician supervision), and CPT 99427 (clinical staff PCM add-on, each additional 30 minutes), with the codes effective January 1, 2022 under the CY 2022 Medicare Physician Fee Schedule final rule. PCM was originally established under HCPCS G2064 and HCPCS G2065 effective January 1, 2020 under the CY 2020 MPFS final rule, with the CPT 99424-99427 framework replacing the G2064/G2065 predecessor codes in 2022.

PCM differs structurally from the Chronic Care Management (CCM) framework in two critical respects. First, PCM is for management of a SINGLE complex chronic condition rather than the multiple-chronic-condition framework that defines CCM. The PCM beneficiary may have other chronic conditions, but the PCM service is specifically targeted to management of one particular complex condition that requires substantial disease-specific care coordination. Second, PCM is commonly furnished by specialists who manage a specific chronic condition rather than primary care practitioners. Common PCM-furnishing specialties include nephrology (chronic kidney disease, end-stage renal disease), cardiology (heart failure, atrial fibrillation, coronary artery disease), pulmonology (chronic obstructive pulmonary disease, asthma, pulmonary hypertension, interstitial lung disease), neurology (Parkinson's disease, multiple sclerosis, epilepsy, dementia), oncology (active cancer treatment, cancer survivorship), endocrinology (complex diabetes, thyroid cancer, adrenal disorders), rheumatology (rheumatoid arthritis, systemic lupus erythematosus, vasculitis), and gastroenterology/hepatology (inflammatory bowel disease, cirrhosis, hepatitis).

For Georgia Medicare beneficiaries, the PCM benefit operates within a state landscape characterized by substantial specialty care delivery infrastructure concentrated in metropolitan areas. Georgia's major academic medical centers (Emory Healthcare, Wellstar Health System, Piedmont Healthcare, Northside Hospital, Augusta University Health, Atrium Health Navicent, Memorial Health, Phoebe Putney Health System, Northeast Georgia Health System) host comprehensive subspecialty divisions delivering PCM across all major specialty domains. Large independent specialty practices (Atlanta Heart Associates, Northeast Georgia Diagnostic Clinic, Georgia Cancer Specialists, Atlanta Gastroenterology Associates, Resurgens Orthopaedics for relevant orthopedic conditions, and many others) provide additional specialty PCM capacity. Rural Georgia specialty access remains a challenge given the workforce concentration in metro Atlanta and a handful of other metropolitan centers, with telehealth PCM delivery providing an important access pathway for rural beneficiaries.

The PCM-CCM coexistence framework is structurally important for the eldercare population. The most common multi-morbid older Medicare beneficiary in Georgia has both: (a) multiple chronic conditions warranting CCM enrollment by a primary care physician, AND (b) one or more complex chronic conditions warranting PCM enrollment by a specialist. CMS allows PCM and CCM to be billed for the same beneficiary in the same calendar month when furnished by different practitioners — typically the primary care physician billing CCM for the overall multi-condition management while a specialist (e.g., nephrologist for CKD4 management, cardiologist for HFrEF management) bills PCM for the single complex condition. The coexistence framework supports comprehensive care coordination across primary care and specialty care without creating duplicate billing issues.

This guide explains how the Medicare PCM benefit works statutorily and clinically, what eligibility looks like for a Georgia Medicare beneficiary with a single complex chronic condition, what the comprehensive disease-specific care plan must include, how the CPT 99424/99425/99426/99427 coding framework operates, how the HCPCS G2064/G2065 predecessor codes worked from 2020-2021, how the single-condition PCM framework relates to the multiple-condition CCM framework, how PCM coordinates with CCM, TCM, BHI, AWV, and other care management benefits, how PCM operates across specific specialty domains including nephrology, cardiology, pulmonology, neurology, oncology, endocrinology, rheumatology, and hepatology, what telehealth PCM delivery looks like for rural Georgia beneficiaries, and what the Georgia PCM delivery landscape provides.

Key Takeaways for Georgia Medicare Beneficiaries

CPT 99424/99425/99426/99427 are the Principal Care Management codes effective January 1, 2022 under the CY 2022 Medicare Physician Fee Schedule final rule. These codes replaced HCPCS G2064/G2065 which were effective January 1, 2020 under the CY 2020 MPFS final rule.
Single complex chronic condition is the foundational eligibility criterion. PCM is for management of one specific complex chronic condition — not the multiple-chronic-condition framework that defines CCM.
Three-month duration: The chronic condition must be expected to last at least three months. This duration threshold is shorter than the CCM 12-month threshold, supporting PCM enrollment for newly diagnosed beneficiaries with rapidly evolving disease management needs.
Significant risk: The condition must place the beneficiary at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death.
Coding framework:
- CPT 99424 — physician/QHP personally furnished PCM, 30+ minutes per calendar month
- CPT 99425 — physician/QHP personally furnished PCM add-on, each additional 30 minutes
- CPT 99426 — clinical staff PCM, 30+ minutes per calendar month directed by physician supervision
- CPT 99427 — clinical staff PCM add-on, each additional 30 minutes
Specialist-orientation: PCM is commonly furnished by specialists managing a specific chronic condition. Common PCM-furnishing specialties include nephrology, cardiology, pulmonology, neurology, oncology, endocrinology, rheumatology, and hepatology.
Comprehensive disease-specific care plan: PCM requires a written, electronic care plan focused on the single complex chronic condition including disease-specific monitoring, medication management, symptom management, planned interventions, coordination with other practitioners, and contingency planning.
Patient consent: PCM requires patient consent before furnishing services.
PCM and CCM can coexist same calendar month: PCM and CCM can be billed for the same beneficiary in the same calendar month when furnished by different practitioners. The PCP typically bills CCM for multi-condition management while a specialist bills PCM for single-condition management.
For Georgia beneficiaries, PCM operates within a state landscape with substantial specialty care delivery (Emory, Wellstar, Piedmont, Northside, Augusta University, Atrium Health Navicent, Memorial Health, Phoebe Putney, Northeast Georgia subspecialty divisions plus large independent specialty practices), with telehealth PCM delivery providing important rural specialty access.

The Federal Framework Underlying the Medicare PCM Benefit

HCPCS G2064/G2065 — PCM Predecessor Codes Effective January 1, 2020

The Medicare PCM benefit was first established through HCPCS G2064 and HCPCS G2065 effective January 1, 2020 under the CY 2020 Medicare Physician Fee Schedule final rule (CMS-1715-F, published November 15, 2019). The CY 2020 framework recognized that the existing CCM coding framework did not capture the substantial care coordination work involved in managing a single complex chronic condition by a specialist or by primary care for a single-condition focus.

The CY 2020 framework structured PCM through two predecessor codes:

HCPCS G2064: Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with required elements.
HCPCS G2065: Comprehensive care management for a single high-risk disease services, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with required elements.

The CY 2020 G2064/G2065 framework operated for two calendar years before being replaced by the CPT 99424-99427 framework in 2022.

CPT 99424/99425/99426/99427 — Effective January 1, 2022 Under the CY 2022 Medicare Physician Fee Schedule

The Medicare PCM benefit was substantially updated effective January 1, 2022 under the CY 2022 Medicare Physician Fee Schedule final rule. The CY 2022 framework replaced HCPCS G2064/G2065 with four new CPT codes that provide more granular time-based coding:

CPT 99424: Principal care management services, for a single high-risk disease, with the following required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death; the condition requires development, monitoring, or revision of a disease-specific care plan; the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.
CPT 99425: Principal care management services, for a single high-risk disease, each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
CPT 99426: Principal care management services, for a single high-risk disease, with the following required elements [same as CPT 99424]; first 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
CPT 99427: Principal care management services, for a single high-risk disease, each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

The CY 2022 framework operates with the same foundational structural requirements as the G2064/G2065 predecessor codes but provides more granular coding to capture both physician/QHP-personally-furnished time and clinical staff time at the 30-minute increment.

The underlying statutory authority for PCM payment is Section 1861(s)(2)(B) of the Social Security Act, which authorizes Medicare payment for services furnished by physicians and certain qualified providers. CMS uses its rulemaking authority under the Medicare Physician Fee Schedule to establish PCM-specific codes within the Section 1861(s)(2)(B) framework.

42 CFR 410.26 — Incident-To Framework Supporting PCM

42 CFR 410.26 establishes the Medicare incident-to framework that permits services furnished by clinical staff to be billed under the supervising physician's NPI when furnished under appropriate physician supervision. PCM clinical staff codes (CPT 99426 and CPT 99427) use the incident-to framework, while the physician-personally-furnished codes (CPT 99424 and CPT 99425) capture physician/QHP time directly.

The PCM Eligibility Criteria

Single Complex Chronic Condition Requirement

The foundational PCM eligibility criterion is that the beneficiary must have a single complex chronic condition for which PCM is furnished. The chronic condition must:

Be expected to last at least three months
Place the beneficiary at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death
Require development, monitoring, or revision of a disease-specific care plan
Require frequent adjustments in the medication regimen and/or be unusually complex due to comorbidities

The single-condition framework allows PCM to be furnished for the management of one particular condition even when the beneficiary has other chronic conditions. The PCM service is specifically targeted to disease-specific management of the identified condition.

Examples of PCM-Eligible Conditions

Common PCM-eligible chronic conditions across specialty domains include:

Nephrology:

Chronic kidney disease (CKD) stage 3b, 4, or 5 (non-dialysis)
End-stage renal disease on dialysis
Polycystic kidney disease
Glomerular diseases
Renal transplant management

Cardiology:

Heart failure with reduced ejection fraction (HFrEF)
Heart failure with preserved ejection fraction (HFpEF)
Atrial fibrillation with anticoagulation requirements
Severe coronary artery disease
Cardiac amyloidosis
Hypertrophic cardiomyopathy
Pulmonary hypertension

Pulmonology:

COPD GOLD stage 3 or 4
Severe persistent asthma
Pulmonary hypertension
Interstitial lung disease
Pulmonary fibrosis
Lung transplant management

Neurology:

Parkinson's disease
Multiple sclerosis
Amyotrophic lateral sclerosis (ALS)
Myasthenia gravis
Epilepsy with frequent seizures
Alzheimer's disease and related dementias

Oncology:

Active cancer treatment
Cancer survivorship for high-risk cancers
Metastatic disease management
Stem cell transplant follow-up
CAR-T therapy follow-up

Endocrinology:

Complex diabetes mellitus (type 1, severely uncontrolled type 2, insulin-pump-dependent)
Diabetes with multiple complications
Thyroid cancer follow-up
Adrenal insufficiency
Pituitary disorders

Rheumatology:

Rheumatoid arthritis on DMARDs or biologics
Systemic lupus erythematosus
Vasculitis
Inflammatory myopathies
Spondyloarthropathies

Gastroenterology/Hepatology:

Inflammatory bowel disease
Liver cirrhosis with portal hypertension
Chronic hepatitis C (active or recent treatment)
Chronic hepatitis B
Pancreatic cancer follow-up
Esophageal cancer follow-up

Infectious Disease:

HIV/AIDS
Tuberculosis
Hepatitis C treatment
Complex skin and soft tissue infections requiring chronic management

Three-Month Duration Requirement

The chronic condition must be expected to last at least three months. This duration threshold is shorter than the CCM 12-month threshold, supporting PCM enrollment for newly diagnosed beneficiaries with rapidly evolving disease management needs. A beneficiary newly diagnosed with HFrEF, for example, may be enrolled in PCM by a cardiologist within weeks of diagnosis even though the disease may not yet have reached the CCM 12-month duration threshold for the underlying chronic conditions.

Significant Risk Requirement

The PCM condition must place the beneficiary at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. The significant risk component requires the managing practitioner to document why the chronic condition places the beneficiary at risk of adverse outcomes. The risk documentation should connect the specific chronic condition to the specific risk of hospitalization or other adverse outcomes.

Complexity Requirements

The condition must require either:

Frequent adjustments in the medication regimen, OR
Management that is unusually complex due to comorbidities

The frequent medication adjustments component captures conditions like HFrEF where guideline-directed medical therapy involves ongoing titration of multiple agents (beta blockers, ACE inhibitors/ARNI, mineralocorticoid receptor antagonists, SGLT2 inhibitors), Parkinson's disease where levodopa and adjunct therapy adjustments are common, and rheumatologic conditions where DMARD or biologic management requires ongoing monitoring and adjustment.

The unusually complex management due to comorbidities component captures conditions like CKD4 where management is complicated by diabetes, hypertension, cardiovascular disease, and metabolic bone disease, and cancer survivorship where management is complicated by treatment-related comorbidities.

Eligible Beneficiary Population

PCM is available to Medicare beneficiaries enrolled in Medicare Part B with a qualifying single complex chronic condition. PCM is available to:

Original Medicare beneficiaries (Part A and Part B fee-for-service)
Medicare Advantage enrollees (subject to plan-specific rules)
Dual-eligible beneficiaries enrolled in both Medicare and Medicaid
Medicare Savings Program beneficiaries

For Georgia dual-eligible beneficiaries with full Medicaid coverage through DCH, the Medicare PCM benefit operates as the primary payer with the QMB program potentially covering Medicare cost-sharing.

The PCM Coding Framework

CPT 99424 — Physician-Personally-Furnished PCM, 30+ Minutes

CPT 99424 is the foundational physician-personally-furnished PCM code. The code captures the first 30 minutes of physician or qualified health care professional time on PCM activities during the calendar month. The physician/QHP must personally furnish the time — this is not delegated to clinical staff.

CPT 99424 is appropriate when the physician/QHP's personal time on PCM activities for the single complex condition reaches the 30-minute threshold. Typical CPT 99424 activities include:

Physician-personally-furnished telephone communication with the beneficiary about disease-specific symptoms, medications, and management
Physician-to-physician communication with other practitioners regarding the beneficiary's condition (e.g., specialist-to-PCP, specialist-to-other-specialist)
Comprehensive medication review and adjustment decisions
Care plan development and revision
Disease-specific monitoring result review and action

CPT 99425 — Physician-Personally-Furnished PCM Add-On

CPT 99425 is the add-on code for additional physician-personally-furnished time beyond the initial 30 minutes captured by CPT 99424. CPT 99425 captures each additional 30 minutes of physician time and may be billed multiple times in the same calendar month when warranted by the complexity and time involved.

CPT 99426 — Clinical Staff PCM, 30+ Minutes

CPT 99426 is the foundational clinical staff PCM code. The code captures the first 30 minutes of clinical staff time on PCM activities during the calendar month under the supervision of the physician/QHP through the 42 CFR 410.26 incident-to framework. Clinical staff who may furnish PCM time include registered nurses, licensed practical nurses, pharmacists, medical assistants, social workers, and other qualified clinical staff.

Typical CPT 99426 clinical staff activities include:

Telephone communication with the beneficiary about disease-specific symptoms and medications
Coordination with other practitioners and providers
Disease-specific patient education
Coordination with home health, community resources, and social services
Monitoring lab result review and follow-up
Medication reconciliation and adherence support

CPT 99427 — Clinical Staff PCM Add-On

CPT 99427 is the add-on code for additional clinical staff time beyond the initial 30 minutes captured by CPT 99426. CPT 99427 captures each additional 30 minutes of clinical staff time and may be billed multiple times in the same calendar month.

Coding Choice Between Physician-Personally-Furnished and Clinical Staff Codes

The choice between CPT 99424/99425 (physician-personally-furnished) and CPT 99426/99427 (clinical staff) depends on who actually furnishes the PCM time during the calendar month:

If the physician/QHP personally furnishes 30+ minutes: bill CPT 99424 (+ CPT 99425 for additional 30-minute increments)
If clinical staff under physician supervision furnishes 30+ minutes: bill CPT 99426 (+ CPT 99427 for additional 30-minute increments)
If both occur in the same calendar month: practices typically bill the physician code if the physician threshold is met; the clinical staff time is captured within the practice's overall PCM management even if not separately billed

The Comprehensive Disease-Specific Care Plan

PCM requires a comprehensive disease-specific care plan focused on the single complex chronic condition. The care plan must be written, must be electronic (stored in the EHR), must be shared with the beneficiary, and must be shared with other relevant practitioners.

Required Care Plan Components

The PCM care plan must include:

Disease-specific problem statement — clear identification of the complex chronic condition being managed under PCM, including disease stage, severity, key clinical features, and prognosis.
Disease-specific monitoring plan — laboratory, imaging, and clinical monitoring requirements with specified frequencies (e.g., quarterly eGFR for CKD, BNP every 3 months for HF, A1C every 3 months for diabetes, FEV1 spirometry annually for COPD).
Medication management plan — disease-specific medication regimen including current medications, planned adjustments, monitoring requirements (e.g., serum digoxin levels, INR for warfarin), and adherence support.
Symptom management — current symptoms and planned symptom management interventions including escalation protocols for symptom worsening.
Planned interventions — disease-specific interventions over the next period including procedures (e.g., dialysis access, device implantation, biologic therapy), lab and imaging follow-up, specialty consultations, and clinical trial considerations.
Communication and coordination with other practitioners — communication plan with PCP, other specialists, home health, and other providers; the communication element is particularly important for PCM given the specialist orientation.
Contingency planning — what the beneficiary and family should do for specific disease-related contingencies (e.g., HF decompensation symptoms, COPD exacerbation, hypoglycemia in complex diabetes).
Goals of care alignment — alignment of the disease management plan with the beneficiary's overall goals of care including advance care planning considerations.

Care Plan Format and Accessibility

The PCM care plan must be electronic (stored in the EHR). The care plan must be shared with the beneficiary in a format the beneficiary can understand. The care plan must be accessible to other practitioners caring for the beneficiary, particularly the primary care physician who may be billing CCM for the multi-condition management.

Care Plan Review and Revision

The PCM care plan must be reviewed and revised based on changes in the beneficiary's condition. Disease-specific changes such as progression of CKD, worsening of HF, COPD exacerbation, or cancer progression should trigger care plan review and revision.

PCM requires patient consent before furnishing services. The consent may be either written or verbal, with specific documentation requirements.

Required Disclosure Elements

The patient consent must disclose:

The nature of PCM services for the single complex chronic condition
That only one practitioner can furnish PCM for a specific condition per calendar month
That the beneficiary may revoke PCM consent at any time
That PCM is subject to standard Part B cost-sharing (deductible plus 20% coinsurance)
That PCM and CCM can coexist when furnished by different practitioners for different scopes (PCM for the single condition; CCM for the multi-condition management)

Documentation Requirements

If consent is verbal, the consent discussion must be documented in the medical record with the date, time, and substance of the discussion. If consent is written, a signed consent form is retained in the medical record.

PCM-CCM Coexistence Framework

The PCM-CCM coexistence framework is structurally important for the eldercare population. PCM and CCM can be billed for the same beneficiary in the same calendar month when furnished by different practitioners.

Common Coexistence Scenario

The most common PCM-CCM coexistence scenario is:

Primary care physician bills CCM (CPT 99490 or related codes) for the multi-condition management of the beneficiary's overall chronic disease picture
Specialist bills PCM (CPT 99424/99425 or CPT 99426/99427) for the single-condition management of one particular complex chronic condition

For example, an 80-year-old Georgia Medicare beneficiary with CKD4, HFrEF, AFib, DM2, and COPD may have:

Her primary care physician (Emory primary care) billing CCM (CPT 99490) monthly for overall multi-condition management
Her nephrologist (Emory nephrology) billing PCM (CPT 99426) monthly for CKD4 management
Her cardiologist (Emory cardiology) billing PCM (CPT 99426) monthly for HFrEF management

The arrangement supports comprehensive care coordination across primary care and multiple specialties without creating duplicate billing issues.

One-PCM-Per-Condition-Per-Practitioner-Per-Month Framework

Each PCM service is specific to one condition and one billing practitioner per calendar month. Multiple specialists may not each bill PCM for the same condition in the same calendar month. However, different specialists may bill PCM for different conditions for the same beneficiary in the same calendar month.

PCM Beyond Specialist Care

While PCM is commonly furnished by specialists, primary care practitioners can also bill PCM when managing a single complex chronic condition. For example, a primary care physician may bill PCM for management of a beneficiary's complex diabetes mellitus with multiple complications, particularly when the primary care management of the diabetes meets the PCM frequency-of-medication-adjustment or complexity-of-comorbidity threshold.

PCM is subject to standard Medicare Part B cost-sharing:

Part B deductible applies
20% coinsurance applies after deductible

PCM is NOT classified as a preventive service and is NOT subject to the ACA Section 4104 cost-sharing waiver. The standard Part B cost-sharing creates a financial obligation for beneficiaries.

For Georgia dual-eligible beneficiaries with full Medicaid coverage through DCH, the Qualified Medicare Beneficiary program covers Medicare cost-sharing including the Part B deductible and 20% coinsurance for PCM. For Specified Low-Income Medicare Beneficiary (SLMB) and Qualifying Individual (QI) program beneficiaries, Medicaid does not cover Medicare cost-sharing — these beneficiaries pay the Part B deductible and 20% coinsurance out-of-pocket unless they have other coverage.

For Georgia Medicare Advantage enrollees, PCM cost-sharing operates under the plan's specific cost-sharing rules.

Coordination With Other Care Management Frameworks

Coordination With Chronic Care Management (CCM)

PCM and CCM can coexist same calendar month when furnished by different practitioners. The PCM service is for a single complex chronic condition; the CCM service is for multiple chronic conditions. The PCM care plan should reference the CCM relationship and coordinate with the primary care CCM activities. The CCM care plan should reference any PCM relationships and incorporate the specialist disease-specific management.

Coordination With Transitional Care Management (TCM)

PCM and TCM can coexist same calendar month when furnished by different practitioners. A specialist may continue PCM activities during the 30-day post-discharge period while the primary care physician bills TCM for the post-discharge transition. Alternatively, the specialist who managed the beneficiary's care during the inpatient stay may bill TCM for the post-discharge transition focusing on the specialty-specific management.

Coordination With Behavioral Health Integration (BHI)

PCM and BHI can coexist same calendar month. The PCM service captures the disease-specific physical health management; the BHI service captures behavioral health integration activities. The two frameworks operate under different coding structures and capture different categories of care management activities.

Coordination With Annual Wellness Visit (AWV)

PCM and AWV can coexist same calendar month. The AWV is an annual preventive encounter that produces a Personalized Prevention Plan Service; PCM is the ongoing single-condition specialty management. The AWV's PPPS can reference and coordinate with the PCM relationships.

Coordination With Remote Patient Monitoring (RPM)

PCM and Remote Patient Monitoring (CPT 99453/99454/99457/99458) can coexist when furnished as separately documented services. Many specialty conditions benefit from remote monitoring (e.g., home blood pressure monitoring for HF, home weight monitoring for HF, home glucose monitoring for diabetes, home spirometry for COPD), with PCM capturing the disease-specific management and RPM capturing the remote monitoring data collection and interpretation.

Telehealth PCM Delivery

PCM is structurally well-suited to substantial telehealth-based delivery:

Physician-personally-furnished time (CPT 99424/99425): Can be furnished through telephone, secure messaging, video, or other non-face-to-face means. Specialist telephone consultations with the beneficiary, specialist-to-PCP communication, and specialist medication management decisions all qualify as PCM physician time.
Clinical staff time (CPT 99426/99427): Can be furnished through telephone, secure messaging, video, or other non-face-to-face means by clinical staff under physician supervision.

Telehealth PCM is particularly important for rural Georgia specialty access given the concentration of subspecialty workforce in metro Atlanta and other metropolitan centers. Rural beneficiaries can receive telehealth-based specialty PCM from urban specialists, supporting access to comprehensive specialty disease management without requiring substantial travel.

Major Georgia academic medical centers have established robust telehealth specialty programs supporting telehealth PCM delivery across nephrology (telehealth nephrology consultation and follow-up), cardiology (telehealth cardiology including device clinic follow-up), pulmonology (telehealth pulmonology for COPD management), neurology (telehealth neurology for Parkinson's, MS, and epilepsy management), and other domains.

Disease-Specific PCM Frameworks

Nephrology PCM

Nephrology PCM is particularly common for management of advanced chronic kidney disease (CKD stage 3b, 4, and 5 non-dialysis) and end-stage renal disease on dialysis. The disease-specific care plan addresses:

eGFR monitoring (quarterly or more frequent)
Anemia management (hemoglobin, ferritin, transferrin saturation, ESA therapy if indicated)
Mineral bone disease management (calcium, phosphorus, PTH, vitamin D, phosphate binders)
Acidosis management (bicarbonate)
Blood pressure management
Diabetes management coordination (for diabetic kidney disease)
Renal replacement therapy planning (dialysis modality, vascular access, transplantation)
Diet and lifestyle modification

Major Georgia nephrology PCM-delivering programs include Emory Nephrology, Wellstar Nephrology Network, Piedmont Nephrology, U.S. Renal Care Georgia, Fresenius Kidney Care Georgia, and DaVita Georgia.

Cardiology PCM

Cardiology PCM is common for management of heart failure (HFrEF and HFpEF), complex AFib with anticoagulation requirements, severe coronary artery disease, cardiac amyloidosis, and pulmonary hypertension. The disease-specific care plan addresses:

HF symptom monitoring (dyspnea, edema, weight)
HF medication titration (beta blockers, ACE-I/ARB/ARNI, MRA, SGLT2 inhibitors)
BNP/NT-proBNP monitoring
Echocardiography monitoring
Device clinic follow-up (ICD, CRT, pacemaker)
Cardiac rehabilitation referral
Anticoagulation management (for AFib)
Coordination with electrophysiology, interventional cardiology, advanced HF/transplant

Major Georgia cardiology PCM-delivering programs include Emory Cardiology, Piedmont Heart Institute, Wellstar Cardiovascular Medicine, Atrium Health Navicent Cardiology, Augusta University Cardiovascular Center, and Atlanta Heart Associates.

Pulmonology PCM

Pulmonology PCM is common for management of severe COPD (GOLD stage 3 or 4), severe persistent asthma, pulmonary hypertension, interstitial lung disease, and pulmonary fibrosis. The disease-specific care plan addresses:

COPD symptom monitoring (dyspnea, sputum, exacerbations)
COPD medication management (LAMA, LABA, ICS, biologics for severe asthma)
Pulmonary rehabilitation referral
Home oxygen therapy management
Vaccination coordination (pneumococcal, influenza, COVID-19, RSV)
Smoking cessation coordination
Lung transplant evaluation if appropriate

Major Georgia pulmonology PCM-delivering programs include Emory Pulmonology, Piedmont Pulmonology, Wellstar Pulmonary Medicine, Augusta University Pulmonology, and various community pulmonology practices.

Neurology PCM

Neurology PCM is common for management of Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, myasthenia gravis, epilepsy with frequent seizures, and Alzheimer's disease and related dementias. The disease-specific care plan addresses:

Disease-specific symptom monitoring
Disease-modifying therapy management (for MS, etc.)
Levodopa and adjunct therapy adjustment (for Parkinson's)
Antiepileptic drug management
Cognitive function monitoring (for dementia)
Functional ability and safety monitoring
Caregiver support coordination

Major Georgia neurology PCM-delivering programs include Emory Neurology, Piedmont Neurology, Augusta University Neurology, and various community neurology practices.

Oncology PCM

Oncology PCM is common for active cancer treatment and cancer survivorship management, particularly for metastatic disease, high-risk early-stage disease, and post-stem cell transplant or post-CAR-T therapy follow-up. The disease-specific care plan addresses:

Cancer-specific staging and treatment plan
Treatment toxicity monitoring (chemotherapy, immunotherapy, targeted therapy)
Symptom management (pain, nausea, fatigue, neuropathy)
Imaging surveillance
Tumor marker monitoring
Coordination with surgical oncology, radiation oncology, palliative care
Survivorship care planning

Major Georgia oncology PCM-delivering programs include Winship Cancer Institute (Emory), Piedmont Cancer Institute, Wellstar Cancer Network, Northside Hospital Cancer Institute, and Georgia Cancer Specialists.

Endocrinology PCM

Endocrinology PCM is common for management of complex diabetes (type 1, severely uncontrolled type 2, insulin-pump-dependent, diabetes with multiple complications), thyroid cancer follow-up, adrenal insufficiency, and pituitary disorders. The disease-specific care plan addresses:

A1C and glucose monitoring
Insulin regimen management
CGM and pump management for insulin-pump-dependent patients
Diabetes complication management coordination
Thyroid hormone management
Adrenal replacement management
Coordination with nephrology, cardiology, ophthalmology, podiatry for diabetes complications

Major Georgia endocrinology PCM-delivering programs include Emory Endocrinology, Piedmont Endocrinology, Wellstar Endocrinology, and various community endocrinology practices.

Rheumatology PCM

Rheumatology PCM is common for management of rheumatoid arthritis on DMARDs or biologics, systemic lupus erythematosus, vasculitis, inflammatory myopathies, and spondyloarthropathies. The disease-specific care plan addresses:

Disease activity monitoring
DMARD and biologic therapy management
Steroid-sparing strategy
Disease-related comorbidity coordination
Infection surveillance for immunosuppressed patients
Vaccination coordination

Gastroenterology/Hepatology PCM

GI/Hepatology PCM is common for management of inflammatory bowel disease, liver cirrhosis with portal hypertension, chronic hepatitis, and certain GI cancers. The disease-specific care plan addresses:

Disease activity monitoring (for IBD)
Biologic therapy management (for IBD)
Variceal surveillance and hepatocellular carcinoma surveillance (for cirrhosis)
Hepatitis-specific antiviral management
Liver transplant evaluation if appropriate

Worked Examples — Six Georgia PCM Scenarios

Example 1: Fulton 70 Nephrology PCM — CKD4 Management at Emory

A 70-year-old Fulton County beneficiary receives nephrology care at Emory Nephrology for stage 4 chronic kidney disease (baseline eGFR 22 ml/min/1.73m²). She has secondary CKD-MBD with elevated PTH (185), elevated phosphorus (5.8), and vitamin D deficiency. She is on calcitriol, sevelamer, ACE inhibitor, and an SGLT2 inhibitor for renoprotection. Her primary care physician at an Emory Healthcare primary care practice bills CCM monthly for her multi-condition picture (DM2, HTN, hyperlipidemia, CKD4).

Her nephrology RN care manager spends 35 minutes during the calendar month on PCM activities specifically focused on her CKD4 management: monthly phone call about symptoms, fluid status, and medication adherence; coordination with the dietitian regarding renal diet recommendations; pre-dialysis access planning education; transplant evaluation status update with the transplant team; medication review for renal dosing; and monitoring of recent lab trends.

The 35 minutes of clinical staff PCM time supports CPT 99426 billing by the nephrology practice. The PCP's CCM (CPT 99490) and the nephrology PCM (CPT 99426) coexist for the same beneficiary in the same calendar month under the PCM-CCM coexistence framework, since they are furnished by different practitioners for different scopes (CCM for multi-condition; PCM for CKD4).

Example 2: DeKalb 75 Cardiology PCM — HFrEF Management at Piedmont

A 75-year-old DeKalb County beneficiary receives cardiology care at Piedmont Heart Institute for HFrEF (LVEF 25%). He is on guideline-directed medical therapy with metoprolol succinate, sacubitril-valsartan, spironolactone, and empagliflozin. He has a CRT-D implanted 18 months ago, and his cardiologist actively manages medication titration to maximally tolerated doses.

His cardiologist spends 35 minutes during the calendar month on PCM activities personally: a 20-minute telephone discussion with the beneficiary regarding symptom trajectory and medication tolerance; a 10-minute phone call with the device clinic regarding recent CRT-D interrogation showing increased ventricular ectopy; and 5 minutes of medication adjustment decision-making after reviewing recent BMP showing eGFR stable but potassium 5.2.

The 35 minutes of physician-personally-furnished PCM time supports CPT 99424 billing. The cardiology PCM is structurally specific to HFrEF management; the beneficiary's primary care physician separately bills CCM for the multi-condition management.

Example 3: Cobb 68 Pulmonology PCM — Severe COPD at Wellstar

A 68-year-old Cobb County beneficiary receives pulmonology care at Wellstar Pulmonary Medicine for severe COPD (GOLD stage 4 with FEV1 28% predicted). He had two COPD exacerbations in the prior six months requiring hospitalization. He is on triple-inhaled therapy (tiotropium-olodaterol plus fluticasone), home oxygen 2 L/min continuously, and is in pulmonary rehabilitation. He has been advised about lung volume reduction surgery and lung transplant evaluation.

His pulmonology RN care manager spends 65 minutes during the calendar month on PCM activities: 25-minute phone call regarding symptom monitoring, exacerbation planning, and inhaler technique; 15-minute coordination with pulmonary rehabilitation regarding progress and adherence; 10-minute coordination with the lung transplant program regarding evaluation status; 8-minute phone call with home health regarding home oxygen and respiratory support; and 7-minute medication review and refill coordination.

The 65 minutes of clinical staff PCM time supports CPT 99426 (first 30 minutes) plus CPT 99427 (additional 30 minutes) billing. The pulmonology PCM is structurally specific to severe COPD management.

Example 4: Worth County 72 Rural Neurology PCM — Parkinson's Disease via Telehealth

A 72-year-old Worth County beneficiary lives in rural southwest Georgia and has Parkinson's disease (Hoehn and Yahr stage 3) requiring frequent levodopa adjustment, dopamine agonist management, and management of motor fluctuations. The nearest neurologist is in Albany (40 miles away), but he receives telehealth-based neurology care from an Emory neurologist through a telehealth specialty access program.

His Emory neurology nurse practitioner spends 32 minutes during the calendar month on PCM activities personally via telehealth: a 20-minute video visit with the beneficiary and his daughter reviewing motor symptoms, on-off periods, and medication response; an 8-minute review of his medication diary and adjustment of carbidopa-levodopa frequency; and 4-minute coordination with the local PCP regarding medication changes and falls risk.

The 32 minutes of NP-personally-furnished PCM time supports CPT 99424 billing. Telehealth PCM delivery enables rural Georgia specialty access where in-person specialty care would require substantial travel.

Example 5: Bibb 80 Oncology PCM — Metastatic Breast Cancer Survivorship at Atrium Health Navicent

An 80-year-old Bibb County beneficiary receives oncology care at Atrium Health Navicent Cancer Center for metastatic estrogen-receptor-positive breast cancer on letrozole plus palbociclib. She has been on the regimen for 18 months with stable disease per recent imaging. She has chronic conditions including HTN, osteoarthritis, and osteoporosis.

Her oncologist spends 32 minutes during the calendar month on PCM activities personally: a 20-minute telephone discussion with the beneficiary and her daughter regarding symptom monitoring (fatigue, neutropenia trend, joint stiffness); 8-minute review of recent CBC showing neutropenia requiring palbociclib dose adjustment; and 4-minute coordination with rheumatology regarding arthritis management given the aromatase inhibitor-related joint symptoms.

The 32 minutes of physician-personally-furnished PCM time supports CPT 99424 billing. The oncology PCM captures the disease-specific cancer survivorship management; the beneficiary's primary care physician separately bills CCM for the multi-condition management.

Example 6: Hall 74 PCM + CCM Coordination — Nephrology PCM + PCP CCM Same Month

A 74-year-old Hall County beneficiary has CKD4 (eGFR 25), HFrEF (LVEF 35%), DM2 with neuropathy, HTN, and obesity. She receives nephrology care at Northeast Georgia Diagnostic Clinic Nephrology for CKD4 management. She receives primary care at a Northeast Georgia Health System primary care practice for overall multi-condition management.

For the calendar month, the following services are billed:

Primary care practice bills CPT 99490 (CCM, 20+ minutes clinical staff time) for the overall multi-condition coordination — including coordination of cardiology follow-up, diabetes management, medication reconciliation across multiple specialists, AWV-recommended preventive services tracking, and care plan maintenance.
Nephrology practice bills CPT 99426 (clinical staff PCM, 30+ minutes) for the specific CKD4 management — including monthly phone call about CKD-specific symptoms and labs, anemia management with ESA therapy, mineral bone disease management, pre-dialysis access education, and transplant evaluation coordination.

The PCM-CCM coexistence framework supports this arrangement structurally — different practitioners for different scopes, each billing the appropriate care management code for the scope of their management activities.

Best Practices for Maximizing PCM Coverage

Identify PCM-eligible beneficiaries systematically — specialty practices should systematically identify which of their beneficiaries meet the single-condition, 3-month duration, and significant-risk criteria warranting PCM enrollment.
Document the single complex chronic condition clearly — the managing practitioner should document specifically which condition supports PCM eligibility with explicit reference to the 3-month duration, significant-risk components, and complexity (frequent medication adjustments or comorbidity complexity).
Establish PCM workflows in specialty practices — meeting the time threshold and documentation requirements consistently requires structured workflows including time tracking, EHR templates for the disease-specific care plan, and clinical staff training.
Time-track PCM activities meticulously — PCM billing requires documentation of physician or clinical staff time during the calendar month. Use EHR-integrated time tracking.
Maintain disease-specific electronic care plans — the care plan must be comprehensive, electronic, and accessible. Disease-specific EHR templates support consistency.
Obtain and document patient consent — verbal or written consent must be documented with the required disclosure elements.
Coordinate with primary care for PCM-CCM coexistence — specialty practices billing PCM should communicate with the beneficiary's primary care physician to coordinate the PCM-CCM coexistence and ensure care plans are aligned.
Use CPT 99424/99425 for physician-personally-furnished time — when the specialist's personal time on PCM activities reaches 30+ minutes per month, bill the physician-personally-furnished codes.
Use CPT 99426/99427 for clinical staff time — when clinical staff under physician supervision furnishes 30+ minutes of PCM activities per month, bill the clinical staff codes.
Use add-on codes for additional time increments — practices should bill CPT 99425 or CPT 99427 add-on codes for additional 30-minute increments beyond the initial 30 minutes captured by CPT 99424 or CPT 99426.
Use telehealth strategically for PCM delivery — telehealth-based PCM supports rural specialty access and beneficiary convenience for many disease-specific management activities.
Coordinate PCM with TCM during post-discharge periods — PCM can continue during the 30-day TCM window when furnished by a different practitioner than the TCM-billing practitioner.
Educate beneficiaries about PCM cost-sharing — PCM carries standard Part B cost-sharing. Beneficiaries should understand the deductible and 20% coinsurance.
Monitor PCM utilization and outcomes — practices delivering PCM should track utilization, beneficiary outcomes, and integration with the broader care management framework.

Common Issues for Georgia PCM Beneficiaries

Awareness gaps — many PCM-eligible beneficiaries and many specialty practices are not aware of the PCM benefit. Practice education can substantially improve uptake.
Confusion about PCM vs. CCM — beneficiaries and providers may be confused about the distinction between PCM (single complex chronic condition) and CCM (multiple chronic conditions). Education on the structural distinction supports appropriate utilization.
PCM-CCM coordination errors — practices may not coordinate effectively when PCM and CCM coexist. Communication between specialty and primary care supports the coexistence framework.
Time tracking burden — PCM billing requires meticulous time tracking. Specialty practices without EHR-integrated time tracking may struggle.
Consent documentation challenges — practices may struggle with the consent documentation requirements, particularly for verbal consent.
Cost-sharing barriers — Part B deductible and 20% coinsurance create financial barriers for some beneficiaries, particularly those without Medicaid wraparound coverage.
Rural specialty access constraints — rural Georgia beneficiaries may face limited specialty access reducing PCM availability despite the telehealth flexibilities.
Disease-specific care plan maintenance — the comprehensive disease-specific care plan must be reviewed and updated. Specialty practices without systematic care plan maintenance workflows may struggle.
Multiple specialist coordination — beneficiaries with multiple complex chronic conditions may have multiple specialists each potentially eligible to bill PCM, requiring coordination to avoid duplicate billing for the same condition.
Specialist time documentation — specialists may not consistently track PCM time given the structural focus on procedure-based or E/M-based payment in many specialty practices.
Patient understanding of single-condition focus — beneficiaries may not understand that PCM is specific to one condition and may have multiple PCM relationships for different conditions.
Communication friction across practices — PCM care plans must be shared with other practitioners, which requires communication infrastructure that not all practices have.
End-of-life care plan alignment — beneficiaries approaching end of life may need PCM care plans aligned with goals of care, which requires advance care planning discussions.
Adoption variation across specialties — PCM adoption varies substantially across specialties, with some specialties (nephrology, cardiology) having higher adoption than others (rheumatology, infectious disease).

FAQ

What is the Medicare Principal Care Management (PCM) benefit?

Medicare PCM is a benefit that pays primary care or specialty practitioners for the disease-specific care coordination work involved in managing a single complex chronic condition. PCM was established initially under HCPCS G2064/G2065 effective January 1, 2020, then replaced by CPT 99424/99425/99426/99427 effective January 1, 2022 under the CY 2022 Medicare Physician Fee Schedule.

How does PCM differ from CCM?

PCM is for management of a single complex chronic condition. CCM is for management of multiple (two or more) chronic conditions. PCM is commonly furnished by specialists; CCM is commonly furnished by primary care.

Who qualifies for PCM?

Medicare beneficiaries qualify for PCM if they have a single complex chronic condition expected to last at least 3 months that places them at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death; that requires development, monitoring, or revision of a disease-specific care plan; and that requires frequent medication adjustments or is unusually complex due to comorbidities.

What conditions qualify for PCM?

Common PCM-eligible conditions include advanced chronic kidney disease, heart failure, complex AFib, severe COPD, severe asthma, Parkinson's disease, multiple sclerosis, active or metastatic cancer, complex diabetes, rheumatoid arthritis on biologics, systemic lupus erythematosus, vasculitis, inflammatory bowel disease, liver cirrhosis, and many others. The supervising practitioner documents which condition qualifies based on clinical judgment.

How is PCM billed?

PCM is billed under four CPT codes: CPT 99424 (physician/QHP personally furnished, 30+ min), CPT 99425 (physician add-on, each additional 30 min), CPT 99426 (clinical staff, 30+ min), and CPT 99427 (clinical staff add-on, each additional 30 min). The codes capture different categories of time (physician personal vs. clinical staff).

Can PCM and CCM be billed for the same beneficiary in the same month?

Yes, when furnished by different practitioners. PCM is for a single complex chronic condition; CCM is for multiple chronic conditions. Typically the specialist bills PCM while the primary care physician bills CCM.

Can multiple specialists each bill PCM for the same beneficiary?

Yes, when each specialist is managing a different condition. For example, a beneficiary may have her nephrologist billing PCM for CKD4 and her cardiologist billing PCM for HFrEF in the same calendar month. Only one practitioner can bill PCM for a specific condition in a given month.

Can a primary care physician bill PCM?

Yes. While PCM is commonly furnished by specialists, primary care practitioners can bill PCM when managing a single complex chronic condition that meets the PCM eligibility criteria.

What is the difference between CPT 99424 and CPT 99426?

CPT 99424 captures physician-personally-furnished PCM time (30+ minutes by the physician or QHP). CPT 99426 captures clinical staff PCM time directed by physician supervision (30+ minutes by RN, LPN, MA, pharmacist, or other clinical staff).

What was the HCPCS G2064/G2065 framework?

HCPCS G2064 (physician-personally-furnished) and HCPCS G2065 (clinical staff) were the PCM predecessor codes effective January 1, 2020 under the CY 2020 MPFS final rule. They were replaced by CPT 99424/99425/99426/99427 effective January 1, 2022 under the CY 2022 MPFS final rule.

What is the comprehensive disease-specific care plan?

The PCM care plan is a written, electronic plan focused on the single complex chronic condition including: disease-specific problem statement; disease-specific monitoring plan; medication management plan; symptom management; planned interventions; communication and coordination with other practitioners; contingency planning; and goals of care alignment.

Yes. PCM requires written or verbal patient consent before furnishing services with required disclosure elements including the nature of PCM services, cost-sharing, the right to revoke, and the PCM-CCM coexistence framework.

How much does PCM cost the beneficiary?

PCM is subject to standard Medicare Part B cost-sharing — the Part B deductible plus 20% coinsurance. PCM is not classified as a preventive service.

The Qualified Medicare Beneficiary (QMB) program covers Medicare cost-sharing including the Part B deductible and 20% coinsurance for PCM. The SLMB and QI programs do not cover Medicare cost-sharing.

Can PCM be furnished via telehealth?

Yes. PCM is structurally well-suited to telehealth delivery. The physician-personally-furnished time and the clinical staff time can both be furnished through telephone, secure messaging, video, or other non-face-to-face means.

How does PCM coordinate with TCM?

PCM and TCM can coexist same calendar month when furnished by different practitioners. A specialist may continue PCM during the 30-day post-discharge TCM window furnished by the primary care physician.

How does PCM coordinate with BHI?

PCM and BHI can coexist same calendar month. PCM captures disease-specific physical health management; BHI captures behavioral health integration activities.

How does PCM coordinate with the AWV?

PCM and AWV can coexist same calendar month. The AWV's Personalized Prevention Plan Service can reference PCM relationships and coordinate with the specialist disease-specific management.

What clinical staff can furnish PCM time under CPT 99426/99427?

Clinical staff who may furnish PCM time include registered nurses, licensed practical nurses, medical assistants, pharmacists, clinical social workers, and other qualified clinical staff under physician supervision through the 42 CFR 410.26 incident-to framework.

Does PCM utilization vary across specialties?

Yes. PCM adoption varies substantially across specialties. Some specialties (nephrology, cardiology, pulmonology, oncology) have higher PCM adoption than others (rheumatology, infectious disease, gastroenterology). Adoption continues to grow as more specialty practices establish PCM workflows.

How does PCM relate to remote patient monitoring (RPM)?

PCM and RPM can coexist when furnished as separately documented services. Many specialty conditions benefit from remote monitoring; PCM captures the disease-specific management while RPM captures the remote monitoring data collection.

Can FQHCs and RHCs bill PCM?

PCM billing rules in FQHC and RHC settings vary. FQHCs and RHCs primarily use the bundled G0511 care management code for CCM and BHI. PCM billing in FQHC/RHC settings may operate differently — practices should consult Palmetto GBA for specific guidance.

What happens if a beneficiary wants to discontinue PCM?

The beneficiary may revoke PCM consent at any time. The practice must cease PCM billing for the calendar month following revocation. The beneficiary may continue receiving routine specialty care; only the PCM-specific billing ceases.

How is PCM documented?

PCM documentation must include: the qualifying single complex chronic condition; the comprehensive disease-specific care plan; the patient consent (date, time, substance of discussion); the time spent during the calendar month (physician personal time and/or clinical staff time); and the specific PCM activities furnished.

Where can I learn more about PCM in Georgia?

Beneficiaries can call 1-800-MEDICARE for general Medicare questions, Palmetto GBA at 1-866-238-9650 for claims questions, or GeorgiaCares SHIP at 1-866-552-4464 for free Medicare counseling.

Where to Get Help in Georgia

Medicare — 1-800-MEDICARE (1-800-633-4227) — general Medicare benefit questions
Palmetto GBA Medicare Administrative Contractor — 1-866-238-9650 — Georgia Medicare claims and provider questions
DCH Medicaid Member Services — 1-866-211-0950 — Georgia Medicaid questions including QMB and dual-eligible coverage
GeorgiaCares SHIP — 1-866-552-4464 — free Medicare counseling and enrollment assistance
Medicare Rights Center — 1-800-333-4114 — national Medicare advocacy organization
Atlanta Legal Aid Society — 404-377-0701 — free legal services for low-income metro Atlanta seniors
Georgia Legal Services Program — 1-800-498-9469 — free legal services for low-income Georgia seniors outside metro Atlanta
211 Georgia — dial 211 — community resource referrals
Eldercare Locator — 1-800-677-1116 — national directory of local senior services
Georgia Department of Public Health — 404-657-2700 — state public health resources
CDC-INFO — 1-800-232-4636 — federal public health information
Emory Healthcare — comprehensive specialty divisions delivering PCM across nephrology, cardiology, pulmonology, neurology, oncology, endocrinology, rheumatology, and other domains
Wellstar Health System — specialty network across north and northwest Georgia
Piedmont Healthcare — Piedmont Heart Institute, Piedmont Cancer Institute, and other specialty divisions delivering PCM
Acentra Health (Medicare QIO for Georgia) — 1-844-455-8708 — quality of care concerns and complaints
Social Security Administration — 1-800-772-1213 — Medicare enrollment and benefit eligibility
Georgia Composite Medical Board — 404-657-6494 — physician licensing and complaints

Sources and Authorities

This guide is based on the following federal authorities:

HCPCS G2064 (physician-personally-furnished PCM) and HCPCS G2065 (clinical staff PCM) effective January 1, 2020 under the CY 2020 Medicare Physician Fee Schedule final rule (CMS-1715-F, published November 15, 2019)
CPT 99424 (physician-personally-furnished PCM, 30+ min), CPT 99425 (add-on each additional 30 min), CPT 99426 (clinical staff PCM, 30+ min), and CPT 99427 (clinical staff add-on each additional 30 min) effective January 1, 2022 under the CY 2022 Medicare Physician Fee Schedule final rule
Section 1861(s)(2)(B) of the Social Security Act — Physician services authority
42 CFR 410.26 — Incident-to framework
CMS Manual System guidance on PCM services
Medicare Learning Network educational materials on PCM

This guide is informational and does not constitute legal, clinical, or coding advice. PCM coverage decisions are made by Palmetto GBA (Georgia's Medicare Administrative Contractor) and Medicare Advantage plans applying federal coding and policy framework. For coverage questions about specific PCM scenarios, beneficiaries and providers should contact 1-800-MEDICARE, the relevant MA plan, or Palmetto GBA directly. Last verified: 2026-05-14.