Prin care mgmt phys ea addl
CPT 99425 is an add-on code for additional time spent managing complex ongoing care for patients with serious chronic conditions by a physician or qualified healthcare professional who serves as their main care coordinator.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Bill 99425 only after reporting base code 99424; you can report multiple units of 99425 in a single month if documentation supports each 30-minute increment
Impact: Each additional 30-minute block adds $58.87 Medicare reimbursement; a patient requiring 120 minutes total yields $176.61 additional revenue beyond the base code
Track time meticulously across the calendar month using time logs documenting specific activities, dates, staff members, and duration to support each 30-minute increment
Impact: Prevents denials for insufficient documentation; proper time tracking protects approximately 15-20% of claims from audit recoupment
Only one practitioner can bill principal care management codes per patient per month; establish clear care coordination agreements if multiple providers are involved
Impact: Avoids claim rejections and prevents compliance issues; ensures your practice captures the full $58.87+ per additional increment rather than losing to another provider
Principal care management codes cannot be billed in the same month as chronic care management (99490-99491) or behavioral health integration codes; choose the highest-value service
Impact: PCM codes typically reimburse 30-50% higher than CCM for complex patients, maximizing revenue by $20-40 per month per patient
Obtain and document written patient consent specific to principal care management services before billing any PCM codes in a calendar year
Impact: Missing consent documentation results in 100% claim denial; proper consent protects all PCM revenue
Service time includes care plan creation/revision, medication management, coordination with other providers, patient/caregiver communication, but excludes any face-to-face visit time already billed separately
Impact: Counting only non-face-to-face time ensures compliant billing and prevents audit penalties averaging $2,000-5,000 per incident
Common denials
Base code 99424 not billed in the same month or missing from the claim
How to appeal: Resubmit claim ensuring 99424 appears first on the claim with 99425 listed as subsequent line items with appropriate units. Include month's complete time log showing total minutes exceed the base threshold plus 30-minute increments
Insufficient documentation of the additional 30-minute time increment or time log missing required elements
How to appeal: Submit detailed time log showing date, duration, staff member, and specific activities for each increment. Include care plan documentation, communication records, and medication management notes totaling the claimed time
Patient consent not documented in medical record or consent outdated
How to appeal: Provide signed and dated patient consent form specific to principal care management obtained before services rendered. If consent exists but was not initially submitted, include with appeal and attestation of consent date
Claim denied due to overlap with chronic care management or other care management services billed same month
How to appeal: Demonstrate patient meets principal care management criteria with single serious high-risk condition. If other codes were billed in error, withdraw those claims and resubmit 99425. Include clinical documentation supporting PCM appropriateness over CCM
Frequently asked questions
What is CPT code 99425 used for?
CPT 99425 is an add-on code for each additional 30 minutes of principal care management services beyond the base code 99424. It's used for ongoing comprehensive care coordination of patients with a single serious high-risk chronic condition requiring substantial management to prevent hospitalization or death.
How much does Medicare pay for CPT 99425 in 2025?
Medicare pays $58.87 for CPT 99425 under the non-facility rate and $49.17 under the facility rate in 2025, based on the national average. Actual payment may vary by geographic locality adjustment.
Can you bill 99425 without 99424?
No, CPT 99425 is an add-on code that can only be billed with base code 99424 in the same calendar month. It cannot be billed independently and will be denied without the base principal care management code.
How many units of 99425 can I bill per month?
You can bill multiple units of 99425 in a single month based on documented time. Each unit represents an additional 30 minutes beyond the base code threshold. For example, 120 total minutes would support the base code plus two additional units of 99425.
What is the difference between 99425 and chronic care management codes?
CPT 99425 is for principal care management of a single serious high-risk condition with substantial morbidity risk, while chronic care management codes (99490-99491) address multiple chronic conditions. PCM codes typically reimburse higher but require more stringent criteria. You cannot bill both in the same month for the same patient.
What documentation is required to bill CPT 99425?
Required documentation includes detailed time logs with dates, activities, and durations; written patient consent; comprehensive care plan for the serious condition; medication management records; communication logs; and evidence the patient meets PCM criteria with a single high-risk serious illness.
What are the RVUs for CPT 99425?
CPT 99425 has a Work RVU of 1.00, Practice Expense RVU of 0.76 (non-facility) or 0.46 (facility), and Malpractice RVU of 0.06, totaling 1.82 RVUs. The 2025 conversion factor is 32.3465.