Basics of Principal care management CPT codes

Principal care management services are provided to patients for a single high-risk disease. There is one complex condition that is chronic and expected to last a minimum of three months that puts the patient at substantial risk of exacerbation, functional decline, hospitalization, or death. The disease-specific care plan related to this condition requires on-going development, monitoring, or revising. Frequent adjustments to the medication regimen are required, or patient comorbidities increase the complexity of the condition’s management. Communication and care coordination between those furnishing care is required on an ongoing basis.

CPT code 99424 is reported once per calendar month for the first 30 minutes of care provided personally by a physician or other qualified health care professional (QHP); CPT code 99425 for each additional 30 minutes. CPT code 99426 is reported once per calendar month for the first 30 minutes of clinical staff time when directed by a physician or other QHP; for each additional 20 minutes, use CPT code 99427.

The new principal care management services guidelines in the CPT 2022 code set indicate that these codes represent services that “focus on the medical and/or psychological needs manifested by a single, complex chronic condition expected to last at least three months and includes establishing, implementing, revising, or monitoring a care plan specific to that single disease.”

Codes 99424 and 99425 should be reported for the service personally provided by a physician or other qualified health care professional (QHP), and codes 99426 and 99427 may be reported for time spent by clinical staff under the direction of a physician or other QHP. Each code in this subsection is reported only when a full 30 minutes of time is spent providing the service during a calendar month. It would not be appropriate to report any code in this subsection if less than 30 minutes is spent providing the service.

Description of CPT code 99424, 99425, 99426 and 99427

Principal care management represents services that focus on the medical and/or psychological needs manifested by a single, complex chronic condition expected to last at least 3 months and includes establishing, implementing, revising, or monitoring a care plan specific to that single disease.

CPT Code 99424 is reported for at least 30 minutes of physician or other qualified health care professional personal time in care management activities during a calendar month.

CPT Code 99425 is reported in conjunction with 99424, when at least an additional 30 minutes of physician or other qualified health care professional personal time is spent in care management activities during the calendar month.

CPT Code 99426 is reported for the first 30 minutes of clinical staff time spent in care management activities during the calendar month. Code 99427 is reported in conjunction with 99426, when at least an additional 30 minutes of clinical staff time is spent in care management activities during the calendar month.

99424 Principal care management services, for a single high-risk disease, with the following required elements:

• one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,
• the condition requires development, monitoring, or revision of disease-specific care plan,
• the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities,
• ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.

99425 each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

99426 Principal care management services, for a single high-risk disease, with the following required elements:

• one complex chronic condition expected to last at least 3 months, and that places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,
• the condition requires development, monitoring, or revision of disease-specific care plan,
• the condition requires frequent adjustments in the medication regimen and/or the management of the condition is unusually complex due to comorbidities,
• ongoing communication and care coordination between relevant practitioners furnishing care;
  first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month.

99427 each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

Read also: Coding Guide for Prolonged Services CPT codes

Do and Don’t for CPT code 99424, 99425, 99426 and 99427

Report CPT code 99425  only in conjunction with 99424

Principal care management services of less than 30 minutes duration in a calendar month are not reported separately.

Do not report CPT 99424, 99425 in the same calendar month with 90951-90970, 99339, 99340, 99374, 99375, 99377, 99378, 99379, 99380, 99426, 99427, 99437, 99439, 99487, 99489, 99490, 99491, 99605, 99606, 99607.

Do not report 99424, 99425 for service time reported with 93792, 93793, 98960, 98961, 98962, 98966, 98967, 98968, 98970, 98971, 98972, 99071, 99078, 99080, 99091, 99358, 99359, 99366, 99367, 99368, 99421, 99422, 99423, 99441, 99442, 99443, 99605, 99606, 99607