2025 CPT code 99425
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Principal Care Management Evaluation and Management > Care Management Services Feed
Additional 30 minutes of principal care management services, personally provided by a physician or other qualified healthcare professional, for a single high-risk chronic condition lasting at least 3 months.
Modifiers 25 and 57 may apply in appropriate circumstances.Consult the AMA CPT manual for detailed modifier usage guidance.
Medical necessity is established by the presence of a single high-risk chronic condition expected to last at least three months, placing the patient at significant risk for adverse events.The complexity of the condition requires frequent medication adjustments and/or intense management due to comorbidities.
The physician or other qualified healthcare professional is responsible for developing, implementing, monitoring, and revising the patient's care plan; coordinating care with other providers; educating the patient and caregiver; and making frequent medication adjustments as needed.
In simple words: This code covers extra time a doctor or qualified healthcare professional spends managing a patient's serious, long-term health problem. It's for each extra 30 minutes beyond the first 30 minutes in a month, focusing on creating a care plan, making changes to medications as needed, and working with other healthcare providers.
This code reports each additional 30 minutes of physician/qualified healthcare professional time beyond the initial 30 minutes (99424) spent on principal care management services in a calendar month.These services address a single high-risk chronic condition expected to last at least three months, posing significant risks such as hospitalization, acute exacerbation, decompensation, functional decline, or death. The services include developing, monitoring, or revising a disease-specific care plan, frequent medication regimen adjustments (if needed), managing complexities due to comorbidities, and coordinating care with other practitioners.
Example 1: A 70-year-old patient with poorly controlled Type 2 diabetes mellitus and diabetic neuropathy experiences recurrent hypoglycemic episodes. The physician spends an additional 30 minutes beyond the initial 30 minutes reviewing medication regimens, coordinating care with an endocrinologist and a podiatrist, and educating the patient on blood glucose monitoring and avoiding hypoglycemia., A 65-year-old patient with chronic heart failure is hospitalized for decompensated heart failure. After discharge, the physician spends an additional 30 minutes beyond the initial 30 minutes to adjust medication, coordinate with a cardiologist and home health nurse, and educate the patient on early warning signs of decompensation., A 55-year-old patient with chronic obstructive pulmonary disease (COPD) experiences frequent exacerbations.An additional 30 minutes beyond the initial 30 minutes are spent by the physician in developing and implementing a comprehensive care plan that includes pulmonary rehabilitation, medication adjustments, and strategies for managing COPD exacerbations.
Detailed documentation should include:
** This code is for services performed personally by the physician or other qualified healthcare professional.For services performed by clinical staff under physician supervision, use codes 99426 and 99427.
- Revenue Code: M5D (SPECIALIST - OTHER)
- RVU: RVUs vary based on geographic location and other factors. Consult the CMS Physician Fee Schedule for current values.
- Global Days: This is an add-on code; it cannot be billed independently. It is appended to 99424.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: Historical fee schedule data is not provided.Consult the CMS Physician Fee Schedule for historical payment rates.
- Specialties:Internal Medicine, Cardiology, Endocrinology, Oncology, Pulmonary Medicine, Geriatrics
- Place of Service:Office, Outpatient Hospital, Inpatient Hospital, other locations as appropriate