2025 CPT Codes for Principal Care Management in Orthopedic Care

​The 2025 Current Procedural Terminology (CPT) codes for Principal Care Management (PCM) reflect the evolving emphasis on coordinated, patient-centric care for individuals with a single, high-risk chronic condition. For orthopedic care, these codes are particularly valuable in managing complex conditions such as chronic osteoarthritis, persistent joint pain, or post-surgical rehabilitation.

2025 CPT Codes for Principal Care Management in Orthopedic Care

2025 CPT Codes for Principal Care Management in Orthopedic Care

What is Principal Care Management (PCM)?
PCM services are designed for patients with a single complex chronic condition that:

• Significantly impacts the patient’s functional status.
• Requires substantial management or coordination of care.
• Demands regular adjustments to treatment plans.

Orthopedic care often involves conditions that align well with PCM billing, such as degenerative joint diseases, fracture recovery, or chronic musculoskeletal pain.

2025 CPT Codes for PCMThe 2025 CPT codes for PCM include the following updates and details for orthopedic care:
PCM for Clinical Staff Time

1. CPT Code 99424
   • Monthly management of a single chronic condition.
   • At least 30 minutes of clinical staff time directed by a physician or qualified healthcare professional.
2. CPT Code 99425
   • Monthly management with at least 60 minutes of clinical staff time.
   • Used when care requires more intensive monitoring and coordination.

PCM for Physician or Qualified Healthcare Professional Time

1. CPT Code 99426
   • Monthly management involving 30 minutes of direct physician or QHP (Qualified Healthcare Professional) time.
   • Often applicable in orthopedic cases with significant care planning.
2. CPT Code 99427
   • Monthly management with at least 60 minutes of physician or QHP time.
   • Designed for highly complex cases requiring detailed oversight.

Key Criteria for PCM Billing in Orthopedic Care
To use PCM codes effectively, the following criteria must be met:

1. Eligible Condition: The patient must have a single chronic condition expected to last at least 3 months and that requires intensive management. Examples include:
   • Chronic osteoarthritis.
   • Severe degenerative disc disease.
   • Post-surgical care for joint replacements.
2. Plan of Care: A documented, comprehensive care plan must outline:
   • Treatment goals.
   • Coordination with physical therapists, pain management specialists, or other providers.
3. Time Requirements: The specified time thresholds for clinical staff or physician time must be met and documented.

Documentation and Compliance Tips

• Detailed Documentation: Include time logs, treatment adjustments, and communication with other providers.
• Patient Consent: Ensure patient consent for PCM services is documented, as it is a requirement for billing.
• Technology Integration: Use EHR systems to track patient interactions, care plans, and outcomes to meet compliance standards.

Benefits of PCM in Orthopedic Care

1. Improved Outcomes: Enhanced monitoring ensures timely interventions for pain management or mobility challenges.
2. Reduced Hospitalizations: Proactive care coordination prevents complications or readmissions.
3. Patient Satisfaction: Regular follow-ups and personalized care plans lead to better patient engagement.

2025 CPT Codes for Principal Care Management in Orthopedic Care

​Challenges in Implementing PCM in Orthopedic Practices
While the use of PCM codes provides significant benefits, orthopedic practices may encounter challenges that require strategic planning to overcome:

1. Staff Training and Workflow Adaptation:
   • Properly training clinical and administrative staff on the documentation and time-tracking requirements for PCM billing can be time-consuming.
   • Practices must ensure workflows accommodate the coordination of care between various providers, such as physical therapists, orthopedic surgeons, and primary care physicians.
2. Technology Integration:
   • Effective PCM management often requires advanced electronic health record (EHR) systems to document care plans, track time spent on care coordination, and communicate seamlessly with other healthcare providers.
   • Smaller practices may face resource constraints when upgrading to more sophisticated systems.
3. Reimbursement Variability:
   • Reimbursement rates for PCM services can vary depending on payer policies. It is essential to understand Medicare and commercial payer guidelines to maximize revenue.
   • Some private payers may not fully cover PCM services or may have specific pre-authorization requirements.
4. Patient Engagement:
   • Patients must be actively involved in their care plans for PCM services to be effective. Orthopedic patients, particularly older adults, may need additional support to adhere to post-surgical recovery or chronic pain management plans.
   • Practices should incorporate patient education and regular communication as part of their PCM strategy.

Steps to Optimize PCM in Orthopedic Practices

1. Leverage Multidisciplinary Teams:
   • Collaborate with physical therapists, pain management specialists, and social workers to address the multifaceted needs of orthopedic patients.
   • Assign clinical staff to handle routine follow-ups, freeing up physician time for complex cases.
2. Streamline Care Coordination:
   • Use case managers or dedicated PCM coordinators to manage patient care plans, appointments, and communication between specialists.
   • Ensure seamless transitions of care, especially for patients moving from surgery to rehabilitation.
3. Track and Measure Performance:
   • Implement key performance indicators (KPIs) to assess the effectiveness of PCM services, such as reduced readmission rates, improved patient-reported outcomes, and increased adherence to treatment plans.
   • Regularly audit time logs and documentation to ensure compliance with PCM billing requirements.
4. Enhance Patient Communication:
   • Utilize technology, such as patient portals and telehealth services, to maintain consistent communication with patients.
   • Provide easy-to-understand educational materials about the importance of care management and the services they are receiving.
5. Understand Payer Policies:
   • Familiarize yourself with Medicare’s PCM requirements, such as billing restrictions, time thresholds, and patient eligibility.
   • Review contracts with commercial payers to identify opportunities for negotiating PCM coverage.

Future Trends for PCM in Orthopedic Care
​The healthcare landscape continues to evolve, and PCM is expected to play a larger role in orthopedic practices. Here are some anticipated trends:

1. Integration with Value-Based Care Models:
   • PCM aligns with value-based care initiatives, emphasizing outcomes over service volume. Orthopedic practices that adopt PCM may see increased reimbursement opportunities through alternative payment models.
2. Advances in Remote Monitoring:
   • Wearable devices and telehealth solutions are becoming integral to PCM. For orthopedic patients, remote monitoring of mobility and pain levels can provide real-time data to guide care decisions.
3. Expanded Scope of Services:
   • PCM codes may expand to include additional services such as nutrition counseling and behavioral health support, both of which are crucial for patients managing chronic orthopedic conditions.
4. Legislative and Policy Changes:
   • The Centers for Medicare & Medicaid Services (CMS) may introduce updates to PCM guidelines, including adjustments to time thresholds or expanded coverage for more conditions. Orthopedic practices should stay informed to adapt quickly.

2025 National Fee Schedule for PCM ServicesFor Medicare, the national average reimbursement rates for PCM services are as follows (subject to regional adjustments based on the Medicare Physician Fee Schedule and Geographic Practice Cost Index):

1. CPT 99424 – $80–$90
   • Care management requiring at least 30 minutes of clinical staff time under physician supervision.
2. CPT 99425 – $140–$160
   • Care management requiring at least 60 minutes of clinical staff time under physician supervision.
3. CPT 99426 – $90–$110
   • Physician or QHP time spent on care management for at least 30 minutes.
4. CPT 99427 – $160–$180
   • Physician or QHP time spent on care management for at least 60 minutes.

Key Note: Ensure claims are submitted with appropriate place-of-service codes (e.g., office, telehealth, or patient home) to avoid denials.

CMS Local Coverage Determinations (LCDs)
While PCM services are generally covered under Medicare, Local Coverage Determinations (LCDs) can vary by Medicare Administrative Contractor (MAC). Key points include:

1. Covered Conditions for PCM in Orthopedics:
   • Chronic osteoarthritis, spinal stenosis, degenerative joint diseases, and post-surgical recovery may qualify.
   • Documentation must detail how the condition meets the definition of a high-risk chronic condition.
2. Medical Necessity Documentation:
   • Include a comprehensive care plan outlining treatment goals, coordination efforts, and expected outcomes.
   • Ensure documentation shows that PCM services are not duplicative of Chronic Care Management (CCM) or Transitional Care Management (TCM) services.
3. Limitations:
   • PCM services are not billable during the same month as certain other care management services unless clearly differentiated.

Refer to your local MAC’s LCDs to confirm specific regional policies.

Clinical Guidelines for PCM in Orthopedic Care
​PCM services for orthopedic patients must adhere to evidence-based clinical guidelines to demonstrate medical necessity. These include:

1. Condition-Specific Management:
   • Osteoarthritis: Regular monitoring for progression, medication adjustments, and coordination with physical therapists.
   • Post-Surgical Recovery: Coordinating rehabilitation services and managing pain to prevent complications.
   • Chronic Back Pain: Collaborating with pain management specialists for multimodal therapy.
2. Documentation Requirements:
   • Evidence of functional limitations or significant risk factors (e.g., obesity, age, or comorbidities).
   • Detailed patient interactions, including care planning and progress evaluations.
3. Care Coordination:
   • Multidisciplinary involvement (e.g., surgeons, physical therapists, and primary care physicians) is critical to optimize outcomes.

Policy and Reimbursement Guidelines for Other Insurance PayersIn-Network Providers

1. Pre-Authorization Requirements:
   • Some payers require pre-authorization for PCM services. Verify whether the patient’s chronic condition qualifies for PCM coverage.
2. Reimbursement Rates:
   • Reimbursement may differ from Medicare. Private payers typically set their own fee schedules, which are often negotiated as part of the provider’s contract.
   • For in-network providers, rates are generally lower but guarantee payment, provided guidelines are met.
3. Payer-Specific Requirements:
   • Blue Cross Blue Shield: Requires detailed documentation of time spent and a clear care plan.
   • UnitedHealthcare: Often mandates prior authorization and may limit PCM services to specific conditions.

Out-of-Network Providers

1. Out-of-Network Rates:
   • Out-of-network reimbursement may be based on a percentage of the usual and customary charges (UCR). Confirm the patient’s out-of-network benefits and cost-sharing obligations.
   • Patients may need to pay upfront and seek reimbursement from their insurer.
2. Policy Variability:
   • Reimbursement policies for out-of-network providers differ by payer and plan type. Some payers (e.g., Aetna) may not cover PCM services for out-of-network providers without significant justification.
3. Patient Financial Responsibility:
   • Clearly communicate out-of-pocket costs to patients when they choose out-of-network care.

Best Practices for Maximizing PCM Reimbursement

1. Verify Insurance Coverage:
   • Confirm whether PCM services are covered for the patient’s plan and chronic condition.
   • Ensure pre-authorization is obtained when required.
2. Adhere to Clinical and Documentation Guidelines:
   • Meet all payer documentation requirements, including detailed care plans and time logs.
3. Use Technology for Compliance:
   • Leverage electronic health records (EHRs) to track PCM time, document care coordination, and ensure adherence to payer policies.
4. Educate Staff and Patients:
   • Train staff on coding and documentation requirements.
   • Inform patients about the benefits and potential costs of PCM services.

2025 CPT Codes for Principal Care Management in Orthopedic Care

Technology and Tools to Support PCM in Orthopedic Care
The effective implementation of Principal Care Management (PCM) in orthopedic practices requires the right technology and tools. These systems help streamline operations, ensure compliance, and improve patient outcomes.

1. Electronic Health Records (EHRs)
EHR systems are critical for documenting PCM services and ensuring compliance with payer requirements. Key features include:

• Time Tracking: Records time spent on care coordination to meet CPT code thresholds.
• Care Plan Management: Enables the creation, sharing, and updating of comprehensive care plans for chronic conditions.
• Alerts and Notifications: Provides reminders for follow-ups and alerts for gaps in care or missed appointments.

Recommended Platforms: Epic, Cerner, AthenaHealth.

2. Remote Patient Monitoring (RPM)
For orthopedic patients, RPM tools enhance PCM by enabling real-time monitoring of health metrics, such as:

• Activity Levels: Track post-operative mobility or rehabilitation progress.
• Pain Scores: Document chronic pain levels, ensuring timely interventions.
• Compliance with Treatment Plans: Monitor adherence to physical therapy exercises or medication regimens.

Examples of RPM Devices:

• Wearable motion trackers for joint rehabilitation.
• Smart devices for recording patient-reported outcomes.

3. Patient Portals
A patient-friendly portal enhances engagement and communication by allowing access to:

• Appointment scheduling.
• Medication instructions and care plans.
• Secure messaging for queries and updates.

Benefits: Increased patient satisfaction, better adherence to care plans, and reduced administrative workload.

4. Billing and Coding Software
Accurate billing is essential for PCM services. Advanced billing software ensures:

• Proper assignment of CPT codes (99424–99427).
• Verification of coverage under Medicare and commercial payers.
• Compliance with LCDs and payer-specific guidelines.

Top Choices: Kareo, NextGen Healthcare, AdvancedMD.

Key Metrics for PCM Performance in Orthopedic Care
Tracking performance metrics ensures that PCM services deliver value while aligning with payer expectations. Important metrics include:
Clinical Outcomes:

1. Reduction in hospital readmissions or emergency department visits.
2. Improvement in functional status or pain scores.
3. Adherence to rehabilitation or treatment plans.

Operational Metrics:

1. Number of PCM-eligible patients enrolled in the program.
2. Average time spent per patient on care coordination.
3. Patient satisfaction scores from post-care surveys.

Financial Metrics:

1. Percentage of PCM claims approved versus denied.
2. Total revenue generated through PCM services.
3. Cost-to-revenue ratio for managing PCM patients.

Compliance Tips for PCM Billing in Orthopedics
Compliance is critical when billing PCM services, especially given the scrutiny on high-cost services in value-based care models. Follow these best practices:

1. Maintain Detailed Documentation:
   • Include the patient’s chronic condition, functional status, and risk factors.
   • Document time spent on care coordination with dates and specifics.
2. Avoid Duplication of Services:
   • Ensure PCM services do not overlap with Chronic Care Management (CCM) or Transitional Care Management (TCM) billed for the same patient in the same month.
3. Understand Payer Policies:
   • Regularly review payer bulletins and updates on PCM coverage and billing requirements.
   • Note variations in requirements between Medicare and commercial payers.
4. Train Staff on Policy Changes:
   • Educate clinical and administrative teams on the latest coding guidelines, documentation needs, and payer-specific policies.

Challenges and Solutions in PCM ImplementationChallenge
1: Patient Enrollment
Patients may hesitate to enroll in PCM services due to concerns about costs or understanding its benefits.
Solution: Provide clear education on the purpose of PCM, its role in improving outcomes, and potential insurance coverage.

Challenge 2: Meeting Time Thresholds
Providers may find it challenging to meet the required time thresholds for billing.
Solution: Use dedicated care coordinators to handle routine follow-ups, freeing physicians for more complex tasks.

Challenge 3: Reimbursement Delays
Some payers may delay reimbursement due to unclear documentation or policy variations.
Solution: Implement quality control audits to verify claims before submission and appeal denied claims promptly.
The Future of PCM in Orthopedic Practices
​Principal Care Management is poised to become an integral component of orthopedic care, especially with the shift toward value-based care models. Innovations such as AI-driven analytics and enhanced remote monitoring tools will further refine care coordination and patient engagement.
Orthopedic practices that adopt PCM services and invest in the necessary training, technology, and infrastructure will be well-positioned to deliver high-quality care, improve patient outcomes, and ensure financial sustainability in the evolving healthcare landscape.

Expanding Opportunities with Principal Care Management (PCM) in Orthopedics
As the demand for specialized care in chronic conditions rises, Principal Care Management (PCM) offers orthopedic practices opportunities to expand their scope of services and revenue streams. By implementing PCM effectively, practices can address the holistic needs of patients while adapting to broader healthcare trends.

1. Integration with Value-Based Care Models
Value-based care emphasizes outcomes over service volume, aligning perfectly with PCM services. For orthopedic practices, PCM can help achieve:

• Better Outcomes: Early intervention and coordinated care for conditions such as chronic arthritis or post-surgical recovery reduce complications.
• Lower Costs: Preventive care and streamlined management can minimize costly hospitalizations or emergency visits.
• Enhanced Reimbursement: Participation in alternative payment models (APMs), such as Accountable Care Organizations (ACOs), often includes financial incentives for PCM services.

2. Expanding PCM Eligibility
Orthopedic practices can expand the reach of PCM services by identifying additional eligible conditions. Examples include:

• Fracture Management: For complex fractures requiring prolonged follow-up and coordination with rehabilitation services.
• Spinal Conditions: Chronic back pain or post-surgical recovery from spinal surgery.
• Joint Disorders: Degenerative conditions like rheumatoid arthritis or osteoarthritis.

By including these conditions under PCM services, practices can address broader patient populations and ensure better continuity of care.

3. Collaboration with Other Specialists
Orthopedic care often intersects with other specialties, creating opportunities for multidisciplinary PCM services:

• Pain Management: Collaboration with pain specialists to manage chronic musculoskeletal pain effectively.
• Physical Therapy: Coordinating rehabilitation programs with physical therapists to maximize functional recovery.
• Primary Care Providers (PCPs): Sharing care plans with PCPs to ensure alignment on chronic condition management.

Effective collaboration not only enhances patient outcomes but also strengthens referral networks and practice reputation.

4. Leveraging Advanced Technology for PCM
As technology evolves, orthopedic practices can integrate innovative tools to optimize PCM services:

• AI-Powered Analytics: Predict patient needs and identify high-risk patients requiring intensive care.
• Telemedicine: Facilitate virtual check-ins for ongoing care management.
• Wearables and IoT Devices: Track patient activity, pain levels, and adherence to treatment plans in real-time.

These technologies improve efficiency and provide valuable data to support compliance and documentation.

5. Enhancing Patient Engagement in PCM
Patient engagement is critical for the success of PCM programs. Orthopedic practices can implement strategies such as:

• Education Initiatives: Provide patients with easy-to-understand resources on the importance of PCM and how it benefits their condition.
• Communication Tools: Use secure messaging systems or patient portals to maintain consistent contact and answer queries.
• Feedback Mechanisms: Regularly survey patients about their PCM experience to identify areas for improvement.

Satisfied and engaged patients are more likely to adhere to treatment plans and recommend the practice to others.

6. Addressing Social Determinants of Health (SDOH)
​Orthopedic practices offering PCM services can address social determinants of health that may impact patient outcomes:

• Transportation: Assist patients in arranging transportation for in-person visits or rehabilitation sessions.
• Nutrition and Lifestyle: Provide access to nutritionists or wellness programs to support recovery and overall health.
• Financial Barriers: Collaborate with patient assistance programs to help those with financial constraints access necessary care.

Incorporating SDOH considerations into PCM services improves health equity and patient outcomes.

7. Revenue Growth and SustainabilityBy fully leveraging PCM codes (99424–99427) and payer-specific reimbursement opportunities, orthopedic practices can achieve:

• Diversified Revenue Streams: PCM services provide additional billing opportunities, complementing traditional fee-for-service models.
• Reduced Claim Denials: Detailed documentation and adherence to payer guidelines minimize the risk of denials.
• Higher Patient Retention: Enhanced patient satisfaction and outcomes foster loyalty, resulting in repeat visits and referrals.

Strategies for Overcoming Common ChallengesChallenge: High Administrative Burden

• Solution: Automate time-tracking and care coordination tasks with EHR integrations to reduce manual work.

Challenge: Payer-Specific Variations

• Solution: Maintain a comprehensive library of payer guidelines to ensure accurate billing and timely reimbursements.

Challenge: Patient Resistance to PCM Enrollment

• Solution: Use patient testimonials and success stories to illustrate the tangible benefits of PCM services.

8. Looking Ahead: Trends and Future ProspectsThe future of PCM in orthopedics is promising, with emerging trends such as:

• Expanded CPT Codes: Expect additional codes to address new care scenarios, such as remote monitoring and more complex chronic conditions.
• Increased Adoption of AI: AI tools will play a larger role in predictive analytics, patient stratification, and outcome measurement.
• Broader Payer Acceptance: As value-based care models gain traction, more payers are likely to adopt PCM services and adjust reimbursement rates accordingly.

2025 CPT Codes for Principal Care Management in Orthopedic Care

Why Orthopedic Practices Need to Partner with GoHealthcare Practice Solutions LLC for Principal Care Management (PCM)In the evolving landscape of healthcare, orthopedic practices face increasing challenges in managing chronic conditions, adhering to compliance guidelines, and optimizing revenue.
GoHealthcare Practice Solutions LLC is uniquely positioned to help orthopedic practices navigate these complexities, especially with the implementation of the 2025 Principal Care Management (PCM) CPT codes (99424–99427). Here’s why partnering with GoHealthcare is the strategic choice for your practice:

1. Expertise in Orthopedic and Revenue Cycle Management (RCM)
GoHealthcare Practice Solutions LLC specializes in orthopedic care management and revenue cycle optimization, ensuring your practice maximizes reimbursements while focusing on patient outcomes. With extensive experience in managing CPT codes and payer-specific policies, GoHealthcare helps you:

• Accurately bill PCM services for chronic conditions like osteoarthritis, spinal disorders, and post-surgical care.
• Minimize claim denials through precise documentation and compliance with payer guidelines.

2. Tailored Solutions for Orthopedic Practices
Every orthopedic practice is unique. GoHealthcare provides customized strategies to align PCM services with your practice’s needs:

• Care Coordination: Streamline communication between surgeons, physical therapists, and pain management specialists.
• Workflow Optimization: Develop efficient processes for care management, reducing administrative burdens on your staff.
• Technology Integration: Implement cutting-edge tools for tracking patient interactions, documenting care plans, and ensuring compliance.

3. Mastery of Compliance and Documentation
Proper documentation is critical for PCM billing and compliance. GoHealthcare ensures your practice adheres to the latest standards:

• CMS Local Coverage Determinations (LCDs): Stay aligned with Medicare requirements for medical necessity and time thresholds.
• Private Payer Policies: Navigate complex reimbursement guidelines for both in-network and out-of-network services.
• Audit Readiness: Prepare your practice for audits with detailed documentation protocols.

4. Proven Track Record in Boosting Revenue
With a deep understanding of RCM best practices, GoHealthcare has a proven history of helping practices:

• Increase reimbursements for care management services.
• Reduce aged accounts receivables and optimize cash flow.
• Negotiate better payer contracts for in-network and out-of-network services.

By focusing on financial sustainability, GoHealthcare ensures your PCM services are not only patient-centered but also profitable.

5. Seamless Integration with Existing Operations
Partnering with GoHealthcare doesn’t disrupt your existing workflows. Instead, we enhance your operations by:

• Training your staff on PCM-specific documentation and coding.
• Offering ongoing support to address challenges with payer policies.
• Providing end-to-end management of your RCM processes, including claim submissions, follow-ups, and appeals.

6. Focus on Patient Outcomes
At GoHealthcare, we prioritize patient-centered care by:

• Enhancing patient engagement through education and communication.
• Ensuring patients receive coordinated, holistic care for chronic orthopedic conditions.
• Supporting practices in addressing social determinants of health, such as transportation and financial barriers.

This focus not only improves patient satisfaction but also boosts your practice’s reputation and retention rates.

7. Insights and Leadership in PCM Trends
As a leader in healthcare solutions, GoHealthcare stays ahead of industry trends, offering:

• Updates on 2025 PCM CPT code changes.
• Guidance on adopting value-based care models.
• Strategies for leveraging new technologies, like remote patient monitoring and AI-driven analytics.

By partnering with GoHealthcare, your practice benefits from forward-thinking strategies that keep you competitive in the orthopedic care market.

8. Commitment to Your Practice’s Success
GoHealthcare is not just a service provider; we are your strategic partner. Our commitment includes:

• 98% Prior Authorization Approval Rate: Ensuring your services are approved and reimbursed efficiently.
• Advanced Technology Solutions: Utilizing HIPAA-compliant systems for secure and efficient operations.
• Proactive Payer Negotiations: Helping you secure favorable rates and terms with insurers.

Partner with GoHealthcare Practice Solutions LLC Today
​Orthopedic practices that implement 2025 PCM CPT codes require expert guidance to ensure compliance, streamline workflows, and maximize revenue. GoHealthcare Practice Solutions LLC provides the expertise, tools, and support needed to achieve these goals, allowing you to focus on delivering exceptional care to your patients.
Contact GoHealthcare Practice Solutions LLC today to elevate your orthopedic practice and unlock the full potential of Principal Care Management (PCM).