2025 CPT code 99426
(Active) Effective Date: N/A Revision Date: N/A Evaluation and Management - Principal Care Management Services Evaluation and Management > Care Management Services > Principal Care Management Services Feed
Principal care management services, for a single high-risk disease, provided by clinical staff (first 30 minutes).
Modifiers may apply depending on the specific circumstances of service.Consult the CPT manual for modifier usage guidelines.
Medical necessity for 99426 is established by a documented single complex chronic condition expected to last at least three months, placing the patient at significant risk for hospitalization, death, or functional decline.The condition requires a disease-specific care plan that must be frequently updated, requiring regular communication with other healthcare professionals. This is also demonstrated by frequent medication adjustments and/or unusual complexity due to comorbidities.
Clinical staff, under the direction of a physician or qualified healthcare professional, are responsible for managing and coordinating care, including developing, implementing, revising, and monitoring the care plan; communicating with other providers; and educating the patient/caregiver.
- Evaluation and Management > Care Management Services > Principal Care Management Services
- Principal Care Management Services
In simple words: This code covers the first 30 minutes of care coordination and planning for a patient with a serious, long-term health problem that requires frequent medical attention and could lead to serious complications.A doctor or other qualified health professional directs a team member to manage and coordinate care for this patient.
This CPT code represents the first 30 minutes of principal care management services provided by clinical staff under the direction of a physician or other qualified healthcare professional.These services are for a single high-risk chronic condition expected to last at least three months and place the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. The condition requires the development, monitoring, or revision of a disease-specific care plan, frequent medication adjustments, and/or complex management due to comorbidities. Ongoing communication and care coordination between relevant practitioners are also included.This code is reported per calendar month.
Example 1: A patient with severe congestive heart failure (CHF) requiring frequent medication adjustments and close monitoring for worsening symptoms.Clinical staff coordinate care with the cardiologist and home health agency, adjusting the care plan as needed., A patient with type 1 diabetes with frequent hypoglycemic episodes and multiple comorbidities. Clinical staff work with the endocrinologist and nutritionist to optimize diabetes management and prevent complications., A patient post-stroke with significant cognitive and physical impairments. Clinical staff coordinate therapy services, home modifications, and caregiver support to maximize functional recovery.
* Comprehensive medical history and assessment of the chronic condition.* Detailed care plan outlining goals, interventions, and monitoring parameters.* Documentation of communication with other providers and care coordination activities.* Records of patient and caregiver education sessions.* Evidence of medical necessity, demonstrating the complexity of the patient’s condition and need for care management services.
** Code 99426 is for clinical staff time only.Use codes 99424 and 99425 for services personally performed by a physician or other qualified healthcare professional.
- Revenue Code: M5D (Specialist - Other)
- RVU: This information is not available in the provided text.Consult the current CPT codebook or relevant payer guidelines for RVU values.
- Global Days: This code is reported per calendar month, not within a global surgical period.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier does not apply to 99426.
- Fee Schedule: This information is not available in the provided text. Consult fee schedules from your payer for the specific time periods.
- Specialties:Multiple specialties may utilize this code, depending on the nature of the patient's chronic condition. Examples include cardiology, endocrinology, neurology, oncology, and geriatrics.
- Place of Service:Office, Home, Assisted Living Facility, Skilled Nursing Facility, other settings where appropriate care coordination can be provided.