Principal Care Management for Biologics Patients: A Dermatology Billing Guide (2026)
If your practice manages patients on biologics — Ilumya, Stelara, Skyrizi, Dupixent, Humira, and the rest — your clinical staff are already doing a lot of uncompensated work: tracking prior authorization renewals, reviewing labs, coordinating refills, fielding patient calls about injection sites and side effects. Principal Care Management (PCM) is the Medicare billing pathway that lets you capture revenue for that work, instead of absorbing it as overhead.
This isn't a new program — PCM codes have existed since 2022 — but it's worth revisiting now because so few dermatology practices actually bill it, and because biologics-heavy derm practices are close to an ideal fit for it. Here's what it actually requires, what it pays, and where the real audit risk sits.
What Principal Care Management actually is
PCM is for patients with one serious, high-risk chronic condition expected to last at least three months, requiring a disease-specific care plan and ongoing clinical staff time outside of office visits (Medical Economics). Severe plaque psoriasis, hidradenitis suppurativa, and moderate-to-severe atopic dermatitis under active biologic management are reasonable fits — the condition is singular, serious, and genuinely requires month-over-month coordination.
That's a narrower bar than Chronic Care Management (CCM), which requires two or more chronic conditions. If your biologics patient only has the one qualifying dermatologic condition, PCM — not CCM — is the applicable code family.
The 2026 CPT codes and rates
| CPT Code | Service | Time per calendar month | In DermEstimator |
|---|---|---|---|
| 99424 | PCM, physician/QHP time | First 30 minutes | Yes — Care Management category |
| 99425 | PCM, physician/QHP time | Each additional 30 minutes | Yes |
| 99426 | PCM, clinical staff time (under general supervision) | First 30 minutes | Yes |
| 99427 | PCM, clinical staff time (under general supervision) | Each additional 30 minutes | Yes |
The clinical staff codes (99426/99427) are the ones most practices overlook — they let an MA or RN log the time, under the physician's general supervision, rather than requiring the physician or NP to personally spend the 30 minutes. That's the more realistic workflow for most derm practices: a biologics-coordination MA tracking PA renewals and lab results across a patient panel, not the physician doing it directly.
These codes, plus the related Chronic Care Management codes (99487, 99489, 99490, 99491) for patients who qualify under that program instead, are already in DermEstimator's fee schedule with current 2026 Medicare rates, now grouped under a dedicated Care Management category in the procedure picker rather than requiring a code-number search.
The four things that have to be documented every month
PCM revenue is real, but it is not passive. To defend the claim, four things need to be true and documented for the billing month, not assumed from a prior visit:
1. One qualifying condition. A single, severe, chronic dermatologic condition expected to last at least three months — not a general "complex patient" designation.
2. A disease-specific care plan. Written, current, and specific to that condition — not a generic template that hasn't been updated since enrollment.
3. At least 30 cumulative minutes of qualifying time in the calendar month. 29 minutes doesn't bill. Time needs to be logged as it happens — PA follow-up calls, lab review, medication coordination — not reconstructed at month-end from memory.
4. Documented patient notification, not necessarily signed consent. Medicare does not require a signed consent form as a condition of payment for care management services. What's required is that the practitioner inform the patient of the service's availability, that only one practitioner can bill it per month, any applicable cost-sharing, and the patient's right to stop at any time — and that this conversation is documented (PYA care management billing guide).
Where PCM billing actually goes wrong
The most common PCM compliance problems aren't exotic — they're the same operational gaps that trip up any recurring, non-visit-based billing code:
- Vague time logs. "Reviewed chart, called patient" with no duration doesn't support 30 cumulative minutes under audit. Log start/stop or duration per activity.
- Stale care plans. A care plan written at enrollment and never revisited looks like a formality, not active management, when a reviewer pulls the record.
- Overlapping claims. CMS restricts billing certain care management codes for the same patient in the same calendar month — the specific overlap rules vary by program, so verify current restrictions before billing more than one care management code for a patient in a given month (ChartSpan on care management overlap risk).
- Eligibility drift. A patient enrolled when their psoriasis was severe may improve on a biologic to the point they no longer meet the "high-risk, requires regular monitoring" bar — eligibility isn't a one-time check at enrollment.
None of this means PCM is risky to bill. It means PCM is a recurring compliance obligation, not a one-time setup — closer to incident-to billing than to a procedure code you bill once per encounter.
One pattern worth avoiding: some PCM guidance online frames patient enrollment around which patients have already met their annual out-of-pocket maximum, so the monthly PCM charge effectively costs them nothing. Be cautious with this framing. Enrollment and billing decisions should be driven by medical necessity and the four criteria above — not by a patient's deductible status. Documentation built around "this patient won't notice the charge" rather than "this patient has a qualifying condition requiring this level of coordination" is the kind of pattern that draws attention under a system-level audit, independent of any single claim's accuracy.
A realistic revenue picture
For a practice with, say, 60 active biologics patients who genuinely meet the PCM criteria, and clinical staff logging the first 30 minutes monthly under 99426 (currently paying in the mid-$60s per Medicare's 2026 non-facility rate), that's a few thousand dollars a month in revenue for coordination work that's largely already happening — it just isn't being captured today. The number scales with how many patients genuinely qualify and how reliably staff log time, not with how aggressively the program is marketed to patients.
That's the real pitch: PCM formalizes and compensates work your biologics-coordination staff are already doing. It is not a reason to expand outreach to patients who don't have a qualifying condition, and it is not a vehicle for billing patients who happen to have low out-of-pocket exposure that month.
Where DermEstimator fits
DermEstimator's fee schedule already includes 99424 through 99427 and the related CCM codes, with current 2026 Medicare rates and a dedicated Care Management category in the procedure picker. If you're estimating patient cost-sharing for a PCM-enrolled patient — relevant for the annual consent conversation about applicable copays — the same payer-specific calculation DermEstimator applies to procedure codes applies here too. See the full code list under features.
DermEstimator doesn't track PCM time logs or care plans — that's an EMR or dedicated care-management workflow function. What it does is make sure the dollar figure in that annual consent conversation reflects your actual contracted rates, the same way it does for every other code in your fee schedule.
The Bottom Line
PCM is a legitimate, under-used revenue pathway for biologics-heavy dermatology practices — the work is already happening, and the codes exist to pay for it. But like incident-to billing, the value only holds up if the four documentation requirements are met every month, for every enrolled patient, not just at the point of enrollment. Build the workflow around medical necessity, keep care plans current, log time as it happens, and the revenue follows without the audit exposure.
Educational information only. This article is not a substitute for review by qualified coding/compliance staff or legal counsel. Verify current CMS PCM/CCM policy, overlap restrictions, and your specific payer contracts before implementing a care management billing program.
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Start Free Trial →Common questions
Does Medicare require a signed consent form for PCM?
No. A signed consent form is not a condition of payment. The practitioner must inform the beneficiary of the service's availability, that only one practitioner can bill it per month, applicable cost-sharing, and the right to stop at any time — and document that this discussion happened (PYA care management billing guide).
Can PCM and CCM be billed for the same patient in the same month?
Overlap rules apply. CMS restricts billing certain care management services for the same patient in the same calendar month, and specific rules vary by program. Verify current overlap restrictions before billing more than one care management code for a patient in a given month (ChartSpan).
Are the CPT codes 99424-99427 already in DermEstimator?
Yes. DermEstimator's fee schedule already includes 99424, 99425, 99426, 99427, and the related chronic care management codes 99487, 99489, 99490, and 99491, grouped under a Care Management category in the procedure picker.
Juhi Mirchandani is the founder of DermEstimator, an AI-powered patient cost estimator built specifically for dermatology practices. She spent 7 years in dermatology operations — medical assistant, clinical coordinator, biller, and office manager — before building DermEstimator to solve the problems she watched every practice fight with daily.