Prin care mgmt staff 1st 30
CPT 99426 covers the first 30 minutes of principal care management services provided by clinical staff under physician supervision for patients with a single serious chronic condition. This is non-face-to-face care coordination work done throughout a calendar month.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
Billing tips
Bill 99426 only once per calendar month for the first 30 minutes of clinical staff time; additional 30-minute increments use 99427
Impact: Prevents bundling denials and ensures proper payment of $61.78 for initial time block
Obtain written patient consent before initiating PCM services and providing first bill; document consent in medical record
Impact: Required element - failure to obtain consent results in 100% denial of all PCM claims
Track all clinical staff time in increments throughout the month using time logs; only count qualifying activities per CMS guidelines
Impact: Accurate time tracking prevents underbilling (lost revenue) and overbilling (audit risk and recoupment)
Ensure patient has only one serious chronic condition; patients with multiple conditions should be billed under CCM codes (99490 series) instead
Impact: Prevents denials for incorrect code selection; PCM and CCM cannot be billed simultaneously for same patient
Document the comprehensive care plan initiated or reviewed during the month, including patient functional status and medication reconciliation
Impact: Core documentation requirement; absence leads to medical necessity denials and potential audit findings
Bill at month-end only after 30 minutes of qualifying time has been documented; partial months under 30 minutes are not billable
Impact: Prevents denials for insufficient time; waiting until threshold met ensures $61.78 payment versus $0
Common denials
Lack of documented patient consent for Principal Care Management services
How to appeal: Submit appeal with copy of signed consent form showing patient agreement to PCM services and understanding of potential cost-sharing. Include date consent was obtained prior to first service date. Ensure consent explicitly mentions PCM, not just general care.
Insufficient documentation of 30 minutes of qualifying clinical staff time during calendar month
How to appeal: Provide detailed time log showing date, duration, and specific activities for each PCM interaction throughout the month. Highlight activities that meet CMS criteria: care coordination, medication management, communication with patient/caregivers, and care planning. Ensure cumulative time meets or exceeds 30 minutes.
Patient does not meet definition of having a single serious chronic condition requiring ongoing management
How to appeal: Submit clinical documentation demonstrating patient has one qualifying high-risk chronic condition placing them at significant risk of hospitalization, exacerbation, or functional decline. Include diagnosis codes, recent hospitalizations or ER visits, medication complexity, and prognosis statement from treating physician.
Concurrent billing with Chronic Care Management (CCM) codes 99490/99439 for same patient and time period
How to appeal: Review patient case to determine correct service: PCM for single serious condition vs CCM for multiple chronic conditions. Submit corrected claim with appropriate code based on patient's actual clinical status. Include explanation of condition count and why selected code is medically appropriate. Note: Cannot bill both services simultaneously.
Frequently asked questions
What is CPT code 99426 used for?
CPT 99426 is used to bill for the first 30 minutes of principal care management (PCM) services provided by clinical staff under physician supervision during a calendar month. It covers non-face-to-face care coordination for patients with a single serious chronic condition requiring ongoing management.
How much does Medicare pay for CPT 99426 in 2025?
Medicare pays $61.78 for CPT 99426 in non-facility settings and $47.55 in facility settings based on the 2025 national average. Actual reimbursement varies by geographic location due to locality adjustments.
What is the difference between CPT 99426 and 99490?
CPT 99426 is for principal care management of patients with one serious chronic condition, while 99490 is for chronic care management of patients with two or more chronic conditions. Both require 20-30 minutes of clinical staff time, but PCM (99426) is for single-condition patients at high risk of deterioration, while CCM (99490) addresses multiple chronic conditions. They cannot be billed together for the same patient.
Can CPT 99426 be billed with an office visit on the same day?
Yes, CPT 99426 can be billed in the same month as office visits (99202-99215), but it represents separate non-face-to-face care management time accumulated throughout the calendar month, not same-day services. The 30 minutes of PCM time must be distinct from face-to-face visit time.
How do I document time for CPT 99426?
Maintain a detailed time log throughout the calendar month documenting each PCM activity with the date, duration in minutes, clinical staff member involved, and specific tasks performed (care coordination, medication review, communication with patient/providers, care planning). Only count qualifying non-face-to-face activities. Bill 99426 once the cumulative time reaches 30 minutes within the calendar month.
Is patient consent required to bill CPT 99426?
Yes, written patient consent is mandatory before billing CPT 99426 for the first time. The consent must inform the patient about PCM services, potential cost-sharing responsibilities, and their right to discontinue services. Consent must be documented in the medical record and obtained before providing billable PCM services.
What are the RVUs for CPT code 99426?
CPT 99426 has a total of 1.91 RVUs in 2025, consisting of 1.0 work RVU, 0.85 non-facility practice expense RVU (0.41 facility), and 0.06 malpractice RVU. These values are based on the CMS 2025 Medicare Physician Fee Schedule.