Medicare pays nephrologists monthly for managing one high-risk kidney condition between office visits. The 2026 national non-facility rate for CPT 99424 is $87.51. This guide covers eligible patients, CPT codes, reimbursement rates, documentation, exclusions, payer rules, and claim steps for your practice.
In this detailed guide, we have discussed everything about PCM billing for nephrology and how Mediremote helps nephrology practices make the process faster and more accurate by streamlining the patient workflow.
What Is PCM Billing for Nephrology?
Medicare Part B codes that are used by nephrologists to bill for non-face-to-face, monthly care coordination of a single, high-risk chronic condition, such as stage 4 or stage 5 chronic kidney disease CKD), or diabetic nephropathy. Patients receiving dialysis and paid under the monthly ESRD capitation codes (90951-90970) are not eligible for PCM in the same month.
Unlike Chronic Care Management (CCM), which requires a patient to have two or more chronic conditions, PCM is tailored for patients whose health risk is driven heavily by one dominant condition that requires frequent monitoring, medication adjustments, lab tracking, and specialist coordination between office visits.
Which CPT Codes Apply to PCM Billing for Nephrology?
These are the codes that are applied for PCM Billing for Nephrology:
| CPT Code | Description | Performed By | 2026 National Non-Facility Rate |
| 99424 | First 30 minutes | Physician or QHP | $87.51 |
| 99425 | Each additional 30 minutes | Physician or QHP | $61.46 |
| 99426 | First 30 minutes | Clinical staff under direction | $67.80 |
| 99427 | Each additional 30 minutes | Clinical staff under direction | $54.11 |
Code 99425 requires 99424, and 99427 requires 99426. A practice cannot report 99424 or 99425 in the same calendar month as 99426 or 99427. Care management time under 30 minutes is not reportable.
Who Can Perform PCM Services in a Nephrology Practice?
The time that is spent by physicians, nurse practitioners and physician assistants can be billed using cpt codes 99424 and 99425. However, the time that is spent by registered nurses and medical assistants under the direction of nephrologists is billed under 99426 and 99427.
The time that clinical staff will spend is not included in 99424 or 99425. The time that is included must be spent by the billing practitioner.
This reduces how much it costs to bill minutes. The nephrologist will have time to make complex decisions and leave the clinical team to carry out routine coordination as part of the care plan.
Which Patients Qualify for PCM Billing for Nephrology?
Patients qualify when one kidney condition is expected to last at least three months, carries significant risk of hospitalization or decline, and requires a disease-specific care plan. Stage 4 and stage 5 pre-dialysis CKD meet these criteria most consistently.
The record must support each element of the CPT descriptor:
- The condition is a single high-risk disease expected to last at least 3 months.
- The condition places the patient at significant risk of hospitalization, acute exacerbation, functional decline, or death.
- The practice develops, monitors, or revises a disease-specific care plan.
- The condition requires frequent medication adjustments, or comorbidities make management unusually complex.
- Relevant practitioners maintain ongoing communication and care coordination.
ICD-10 specificity supports medical necessity. Report N18.4 for stage 4 CKD and N18.5 for stage 5 CKD. A note that says only “CKD” codes to N18.9 and weakens the claim. N18.6 (ESRD) is not a PCM diagnosis for patients billed under the monthly dialysis capitation codes.
What Are the Nephrology PCM Reimbursement Rates in 2026?
Payment varies by locality through the geographic practice cost index, and the 2026 conversion factor is $33.40. Patients owe 20% Part B coinsurance unless supplemental coverage applies. Confirm your locality’s exact amounts in the CMS Physician Fee Schedule Look-Up Tool before building projections.
| Monthly Time Billed | Codes | Revenue Per Patient |
| 30 minutes, clinical staff | 99426 | $67.80 |
| 60 minutes, clinical staff | 99426 + 99427 | $121.91 |
| 30 minutes, physician | 99424 | $87.51 |
| 60 minutes, physician | 99424 + 99425 | $148.97 |
What Documentation Does PCM Billing for Nephrology Require?
According to the AAPC guidance, PCM billing for nephrology practices should maintain the following records:
Qualifying kidney condition: This must be documented. Indicate what was diagnosed and the severity. Note any clinical findings and risks associated with the diagnosis. Chronic kidney disease (CKD) does not automatically qualify a patient for PCM
Condition-specific care plan: Record treatment goals, medication management, relevant laboratory monitoring, follow-up schedules, and interventions related to the patient’s kidney condition.
Patient consent: Document the patient’s consent to PCM services, including applicable cost-sharing responsibilities and the right to discontinue participation.
Initiating visit: Document the initial qualifying visit if applicable, according to applicable Medicare rules.
Service logs for monthly visits: Document date of service, task performed, who was involved, and duration of the service. This must be able to show that the service provided meets the required CPT code and minimum duration.
Care coordination: Document communications with primary care providers and other specialists, referrals, medication-related concerns, and follow-up actions.
Clinical monitoring: Document relevant lab results, prescriptions, and clinical decisions.
How to Bill PCM in a Nephrology Practice?
These are the steps to follow when billing for PCM:
- Confirm eligibility. Verify the CKD stage, the ICD-10 code, and the three-month expected duration.
- Document consent. Obtain consent before the first billed month. Explain that only one practitioner bills PCM per condition each month.
- Build the care plan. Record goals, medications, lab targets, and coordinating practitioners.
- Track time. Log every minute by patient. Exclude minutes billed under any other code.
- Select the code. Report 99424 for 30 to 59 minutes. Add one unit of 99425 at 60 minutes and a second unit at 90 minutes. Clinical staff time follows the same pattern with 99426 and 99427.
- Submit and reconcile. Submit the claim once the month’s total is final. Match each payment to the monthly time log.
What Billing Rules and Exclusions Apply to PCM Billing for Nephrology?
PCM billing for nephrology prohibits same-month reporting with ESRD services 90951–90970, chronic care management codes, and care plan oversight codes. Only one practitioner bills PCM per month for a given condition.
Dialysis patients paid under monthly capitation codes 90951–90970 therefore do not qualify for PCM that month. Review these rules before enrolling any patient:
- ESRD services 90951–90970: No PCM in the same month.
- CCM and complex CCM (99490, 99439, 99491, 99437, 99487, 99489): No PCM in the same month.
- Care plan oversight (99339, 99340, 99374–99380) and pharmacist MTM (99605–99607): No PCM in the same month.
- E/M visits and remote patient monitoring: Both can occur in the same month when the practice does not count the same time twice.
- Multiple specialists: Each can bill PCM for a different condition at the same time.
What Are Common PCM Billing Errors in Nephrology?
If we talk about billing errors in nephrology, that usually includes inconsistent time tracking, documentation gaps, and complex rules. Top PCM billing errors in nephrology:
Inconsistent Time Tracking:
PCM requires a specific amount of non-face-to-face care time per month (typically at least 30 minutes of clinician or care team time). If the time is not properly recorded and the practice is relying on memory or paper logs rather than verified digital timestamps, it will lead to a high rate of audit failures and denials.
Missing Critical details:
PCM is billed when a disease-specific care plan has been established, updated or reviewed. Without an official and active care plan documented in the EHR, this will result in immediate denials relating to medical necessity and documentation.
Mix-ups in Care Coordination:
If you are also claiming any other Care Management services at the same time as PCM, such as Chronic Care Management (CCM), Transitional Care Management (TCM) or certain ESRD monthly capitation payments (MCP), for the same time period, then you will incur duplicate billing edits and rejections.
Mismatched Diagnosis Codes:
Nephrology PCM is built around advanced, pre-dialysis CKD, typically stage 4 (N18.4) or stage 5 (N18.5). If the diagnosis code on the claim does not match the clinical narrative, or if N18.6 (ESRD) is reported for a patient paid under monthly dialysis capitation, the payer will likely deny the claim.
Confusion in Rules:
The confusion around what is required to be included in non-face-to-face care coordination, medication management, and clinical review, which may have been included in face-to-face office visits or monthly dialysis capitation, means claims will be flagged for compliance.
Lack of Patient Consent:
Verbal or written informed patient consent must be obtained prior to providing the service. Informed consent must include information about potential costs. This will often cause issues when audited by Payers.
How Does PCM Differ From CCM in Nephrology?
There are a number of qualifying conditions due to which PCM and CCM differ from each other; they are explained as:
Conditions:
CCM requires two or more chronic conditions, such as managing a patient with both chronic kidney disease and hypertension.
PCM focuses on a single complex chronic condition, such as stage 4 or stage 5 CKD in a patient who is not on dialysis.
Duration:
CCM is expected to last at least 12 months or until the end of life, while PCM is expected to last at least 3 months.
Time Requirements Per Month:
CCM requires a minimum of 20 minutes of non-face-to-face care coordination, while PCM requires 30 minutes of care management related to a specific disease per calendar month
Providers:
CCM is generally billed by primary care providers who coordinate across multiple broad conditions and specialists.
PCM is utilized by specialists, such as nephrologists, who own and manage the intensive treatment plan for a single high-risk organ.
Billing:
They cannot be billed for a same patient in the same calendar month, as both are Medicare Part B care management services
How Can Your Practice Launch PCM Billing for Nephrology?
Enroll 25-50 stage 4/5 CKD patients. Assign 1 staff member. Use templates to obtain consents and track time. Begin with CPT Code 99426. The first 30 minutes will be done by clinical staff and under the supervision of the nephrologist.
After reviewing the first 3 months of claims, you can scale this panel up. Turning unbillable coordination into 12 monthly claims per patient. For practices that track their time and consents accurately, PCM can become a predictable revenue source for nephrology.
FAQs
Can nephrologists bill PCM for dialysis patients?
No. Nephrology practitioners cannot generally claim Principal Care Management (PCM) or Chronic Care Management (CCM) for patients undergoing active monthly End-Stage Renal Disease (ESRD) dialysis.
How many minutes does CPT 99424 require?
A minimum of 30 minutes must be documented for CPT 99424. Each additional 30 minutes of care management by the personal physician or QHP would generate an extra 99425 unit.
Can clinical staff perform PCM services in a nephrology practice?
Yes. Principal Care Management (PCM) can be provided by clinical staff within a nephrology practice under the general supervision of a nephrology practitioner or other qualified healthcare professional.
Can a practice bill PCM and CCM for the same patient in the same month?
No, the same practice cannot bill both Chronic Care Management (CCM) and Principal Care Management (PCM) for the same patient in the same calendar month
How much does Medicare pay for nephrology PCM in 2026?
Medicare’s 2026 national non-facility rates are $87.51 for 99424, $61.46 for 99425, $67.80 for 99426, and $54.11 for 99427.
What Is the Next Step to Capture PCM Revenue in Your Nephrology Practice?
Every hurdle in this guide costs your practice staff hours. Nurses chase missing readings, billing teams rebuild time logs, and claims stall on thin documentation. Mediremote removes that workload and keeps your nephrologists focused on kidney care.
Your practice keeps clinical control. Mediremote provides an eligibility list, and your physicians choose the patients, obtain consent, and sign the orders. Do not let another month of unbilled care coordination pass.