CPT 99424E&M

Prin care mgmt phys 1st 30

CPT 99424 covers the first 30 minutes of principal care management services provided by a physician or qualified healthcare professional for patients with a single serious chronic condition. This is monthly management time that includes care coordination, medication management, and comprehensive care planning.

Showing rates for

National Average

Base Medicare rate

$80.87

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.45

PE RVU (NF)

0.93

MP RVU

0.12

Total RVU

2.5

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Implement time-tracking systems that distinguish PCM activities from other care management services, documenting each qualifying activity with date, time duration, and staff member performing the task
Impact: Prevents denials worth $80.87 per patient per month and supports audit defense; practices report 25-40% increase in successful PCM billing with proper time logs
Obtain and document written patient consent for PCM services before the first billing, including explanation of cost-sharing responsibilities and the patient's right to decline
Impact: Required element preventing 100% denial; missing consent is the #1 reason for PCM claim rejections
Bill 99424 only once per calendar month, even if multiple 30-minute increments are provided; use add-on code 99425 for each additional 30 minutes beyond the first
Impact: Captures additional $66.19 per additional 30 minutes with code 99425 rather than losing reimbursement for time over 30 minutes
Do not bill 99424 in the same month as CCM (99490), TCM (99495/99496), or BHI (99484) for the same patient; these services are mutually exclusive
Impact: Prevents bundling denials and recoupment; choose the highest-value service based on actual time spent and clinical appropriateness
Document the single serious chronic condition being managed and why it qualifies as placing patient at significant risk, referencing specific clinical indicators like recent hospitalizations or declining functional status
Impact: Strengthens medical necessity defense during audits; practices with condition-specific documentation experience 60% fewer medical review requests
Ensure the comprehensive electronic care plan is shared with the patient/caregiver and updated at least annually or when the patient's condition changes significantly

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Frequently asked questions

What is CPT code 99424 used for?

CPT 99424 is used to bill for the first 30 minutes of Principal Care Management services provided during a calendar month for patients with a single serious chronic condition. This includes non-face-to-face care coordination, comprehensive care planning, medication management, and communication with the patient and other healthcare providers for conditions that place the patient at significant risk of hospitalization or functional decline.

How much does Medicare pay for CPT 99424 in 2025?

Medicare pays $80.87 for CPT 99424 in 2025 under the non-facility rate (national average). The facility rate is $72.13. The code carries 2.5 total RVUs (1.45 work RVU, 0.93 non-facility PE RVU, 0.12 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 99424 and 99490?

CPT 99424 (Principal Care Management) is for patients with a single serious chronic condition requiring at least 30 minutes monthly, while 99490 (Chronic Care Management) covers patients with two or more chronic conditions requiring at least 20 minutes monthly. PCM focuses on intensive management of one high-risk condition, whereas CCM addresses multiple conditions. These codes cannot be billed together in the same calendar month for the same patient.

Can CPT 99424 be billed with an office visit on the same day?

Yes, CPT 99424 can be billed on the same day as an office visit (E/M service) when initiating PCM services, using modifier 25 on the E/M code to indicate a separately identifiable service. However, the time spent in the face-to-face visit does not count toward the 30-minute PCM time requirement. PCM time must be non-face-to-face care management activities performed during the calendar month.

What qualifies as a serious chronic condition for billing 99424?

A serious chronic condition for 99424 must be a single condition expected to last at least three months that places the patient at significant risk of death, acute exacerbation, decompensation, functional decline, or hospitalization. Examples include advanced heart failure (NYHA Class III-IV), severe COPD requiring home oxygen, advanced dementia, chronic kidney disease stage 4-5, or poorly controlled diabetes with multiple complications. The condition must dominate the patient's care plan.

Do I need patient consent to bill CPT 99424?

Yes, patient consent is required before billing CPT 99424 for the first time. The consent must be documented (written or verbal) and should inform the patient about PCM services, their cost-sharing responsibility, that only one practitioner can furnish and bill the service per month, and that the patient has the right to decline. Missing consent is a common reason for claim denials.

Can clinical staff time count toward the 30 minutes for CPT 99424?

Yes, time spent by clinical staff (RNs, LPNs, medical assistants, health educators) performing PCM activities under the general supervision of the billing physician or qualified healthcare professional counts toward the 30-minute threshold for CPT 99424. This allows the physician to delegate appropriate care coordination tasks while maintaining oversight, making PCM services more operationally efficient for practices.