2025 CPT code 99427
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Principal Care Management - Care Management Services Evaluation and Management Feed
This code represents additional 30-minute increments of clinical staff time for principal care management services beyond the initial 30 minutes (99426), for patients with complex chronic conditions.
Modifiers may be applicable depending on the circumstances of service. Consult the AMA CPT manual and payer guidelines for specific modifier rules.
Medical necessity is established by the presence of a complex chronic condition expected to last at least three months, which places the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death, and requires ongoing care management services to reduce these risks.
Clinical staff, under the direction of a physician or qualified healthcare professional, are responsible for providing the care management services. The physician or qualified healthcare professional oversees the care plan and coordinates care with other providers.
- Evaluation and Management
- Evaluation and Management > Care Management Services > Principal Care Management Services
In simple words: This code is for extra time spent by a doctor's office staff helping a patient with a serious long-term illness.It's used when the staff spends an extra 30 minutes beyond the first 30 minutes helping with their care plan. The patient's illness is expected to last at least three months, and is serious enough that they are at risk of dying, needing the hospital, or getting much sicker.
CPT code 99427 designates each additional 30-minute interval of clinical staff time dedicated to principal care management services for a patient with a complex chronic condition, following the initial 30 minutes documented using code 99426.This complex chronic condition is anticipated to persist for at least three months and presents a significant risk of mortality, acute exacerbation, decompensation, functional decline, or hospitalization.The clinical staff, under the direction of a physician or qualified healthcare professional, contributes to developing, revising, or monitoring the patient's disease-specific care plan.The condition necessitates frequent medication adjustments, or its management is unusually complex due to comorbidities.The service also encompasses communication and coordination with other healthcare providers involved in the patient's care.
Example 1: A 65-year-old patient with type 2 diabetes and severe heart failure requires extensive care coordination, including medication management, dietary adjustments, and regular monitoring of vital signs. The clinical staff spends an additional 30 minutes each month adjusting medication and coordinating with specialists., A 72-year-old patient with chronic obstructive pulmonary disease (COPD) experiences frequent exacerbations and requires ongoing care management, including pulmonary rehabilitation and oxygen therapy. The clinical staff spends an additional 30 minutes each month monitoring the patient's symptoms, coordinating care with respiratory therapists and specialists, and modifying the treatment plan as needed. , An 80-year-old patient with Alzheimer's disease and multiple comorbidities requires assistance with activities of daily living (ADLs) and ongoing monitoring to prevent falls and hospitalizations.The clinical staff spends an additional 30 minutes each month educating family caregivers on managing the patient's condition.
Detailed notes documenting the patient's chronic condition, the specific services provided, the time spent on each service, and the care coordination efforts.The documentation should clearly demonstrate the medical necessity of the services.Progress notes should reflect the clinical staff's contributions and the physician's oversight.
** This code is specifically for additional time spent by clinical staff beyond the initial 30 minutes documented with 99426.Careful documentation is crucial to justify the use of this code.
- Revenue Code: M5D (SPECIALIST - OTHER)
- RVU: The RVUs for this code will vary based on geographic location and other factors. Consult the appropriate payer's fee schedule for the most accurate information.
- Global Days: This is an add-on code and does not have a global period.The global period is determined by the primary procedure code reported with 99427.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier does not apply to this code, as it represents clinical staff time under physician supervision.
- Fee Schedule: Historical fee schedule data is not provided in the source.Refer to payer-specific fee schedules for historical reimbursement rates.
- Specialties:Family Medicine, Internal Medicine, Cardiology, Pulmonology, Geriatrics, and other specialties treating chronic conditions.
- Place of Service:Office, Home, Assisted Living Facility, Skilled Nursing Facility