Reimbursement
$87.51
Threshold
30m
2026 Status
Active
What is CPT Code 99424?
CPT 99424 is defined as: Principal care management services, for a single high-risk disease, first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. This service is designed for patients with one complex chronic condition that is expected to last at least 3 months and places the patient at high risk of hospitalization or acute exacerbation.
This code is primarily used for PCM services. It falls under the category of Care Management / PCM and is valid for the 2026 calendar year according to the CMS Physician Fee Schedule.
2026 RVU Components
Relative Value Units (Non-Facility)
Work RVU
1.45
Physician Effort
PE (Non-Fac)
1.06
Practice Expense
Malpractice
0.11
Risk Factor
Total RVU
2.62
Note: [(Work RVU * Work GPCI) + (PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor
2026 CMS Policy Intelligence
efficiency shield
Protected from the -2.5% productivity adjustment (Time-based care management service).
specialist revenue optimization
PCM generates higher reimbursement ($83.50) than staff-led CCM ($61.96 for 99490), rewarding high-intensity specialist physician time.
fqhc rhc transition
G0511 is sunsetted. FQHCs must now itemize and bill 99424 for physician-led PCM to capture appropriate complexity.
Administrative Framework
Operational Requirements
minimum time
30 minutes personally performed by Physician or QHP per calendar month.
condition count
Single high-risk chronic condition ONLY (unlike CCM's 2+ requirement).
frequency
Once per calendar month.
provider type
Must be performed by MD, DO, NP, PA (not clinical staff).
Compliance Checklist
Audit Defense
condition justification
Clear documentation of why this condition is 'high-risk' and requires specialized PCM instead of generic CCM.
time tracking
Audit risk if time is shared with clinical staff; 99424 requires personal physician time.
2026 Update
Medicare audits target the use of 99424 when physician effort is not clearly documented. Ensure logs distinguish between staff time (99426) and MD time (99424).
Common Clinical Scenarios
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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