CPT 99426E&M

Prin care mgmt staff 1st 30

CPT 99426 covers the first 30 minutes of staff time per month spent coordinating care for patients with a single serious chronic condition. This includes tasks like arranging specialty care, monitoring treatment plans, and communicating with patients between office visits.

Showing rates for

National Average

Base Medicare rate

$61.78

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

PE RVU (NF)

0.85

MP RVU

0.06

Total RVU

1.91

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

NCCI bundling edits

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Billing tips

Bill only once per calendar month, regardless of how many 30-minute increments are completed. Use 99427 for each additional 30 minutes.
Impact: Prevents automatic denials; proper use of 99427 can add $50.68 per additional 30-minute increment
Document all staff time to the exact minute with detailed activity logs showing dates, duration, and specific care coordination tasks performed.
Impact: Reduces audit risk and supports medical necessity; missing time logs account for 60% of PrCM denials
Obtain written patient consent before initiating PrCM services and document the consent in the medical record.
Impact: Required element; lack of documented consent results in 100% claim denial and potential refund liability
Ensure the patient has only ONE serious chronic condition. Patients with multiple chronic conditions should be billed under CCM codes (99490 series) instead.
Impact: Prevents denials due to incorrect code selection; CCM codes may yield higher reimbursement for multi-condition patients
Bill at the end of the calendar month once 30 minutes of qualifying time has been documented, not in advance.
Impact: Ensures compliance with Medicare billing rules; premature billing triggers prepayment review
Verify that PrCM services are not being billed concurrently with CCM, TCM, or RPM services for the same patient in the same month.
Impact: These services cannot be billed together per CMS guidelines; doing so results in automatic denial of all codes

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Frequently asked questions

What is the difference between CPT 99426 and 99424?

CPT 99426 is for clinical staff time providing Principal Care Management services (first 30 minutes), while 99424 is for physician/qualified healthcare professional time. Most practices use 99426 since it allows clinical staff under general supervision to perform the work, making it more cost-effective. Both codes pay the same Medicare rate of $61.78 non-facility.

How much does Medicare pay for CPT code 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 rates. The code has a total RVU of 1.91 (1.0 work RVU, 0.85 non-facility PE RVU, 0.06 MP RVU).

Can you bill 99426 and a regular office visit on the same day?

No, 99426 represents non-face-to-face care management services provided throughout the calendar month, not on a specific date of service. The time counted toward 99426 cannot include time during face-to-face visits. However, you can bill an E/M visit and 99426 in the same month as long as the PrCM time is separate from the visit.

What counts as qualifying time for CPT 99426?

Qualifying time includes clinical staff activities such as care coordination with specialists, medication management, patient/caregiver communication, care plan revisions, monitoring test results, and arranging community resources. Non-qualifying time includes appointment scheduling, insurance verification, routine prescription refills without assessment, and other administrative tasks.

Can you bill 99426 and chronic care management codes together?

No, PrCM codes (99424-99427) cannot be billed in the same calendar month as CCM codes (99490, 99491, 99439, 99487, 99489), Transitional Care Management, or Behavioral Health Integration services. A practice must choose the most appropriate care management code based on the patient's condition and service provided.

Do I need patient consent to bill CPT 99426?

Yes, written patient consent is mandatory before initiating Principal Care Management services. The consent must inform the patient about the service, applicable cost-sharing, their right to stop services, and that only one practitioner can bill for care management per month. Lack of documented consent will result in claim denial.

How many times can you bill 99426 per month?

CPT 99426 can only be billed once per calendar month per patient. It represents the first 30 minutes of PrCM clinical staff time. If additional 30-minute increments are provided in the same month, use add-on code 99427 for each additional 30 minutes (pays $50.68 for 2025).