Reimbursement
$61.46
Threshold
30m
2026 Status
Active
What is CPT Code 99425?
CPT 99425 is defined as: Principal care management services, for a single high-risk disease, 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).
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
Physician Effort
PE (Non-Fac)
0.77
Practice Expense
Malpractice
0.07
Risk Factor
Total RVU
1.84
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 (Care Management service).
revenue capture
Physician-led PCM add-ons ($60.12) are more valuable than staff-led add-ons ($48.43 for 99427), reflecting higher medical decision-making intensity.
fqhc rhc transition
FQHCs can now scale PCM reimbursement based on actual physician effort using 99425 units instead of the flat G0511.
Administrative Framework
Place of Service
Key Modifiers
Operational Requirements
minimum time
Each additional 30 minutes (Threshold starts at 60 total personal Physician/QHP minutes).
primary code
99424 (Must be billed for the first 30 minutes).
frequency
Multiple units allowed in a calendar month if medical necessity is documented.
provider type
Personal physician/QHP time only.
Compliance Checklist
Audit Defense
time clash
Ensure MD/QHP time does not overlap with time billed for other management services (e.g., CCM or RPM).
decision log
Audit defensive notes should focus on the 'why' behind the extra physician time (e.g., 'coordinated with transplant team').
2026 Update
Medicare audits focus on high-volume 99425 billing. Maintain detailed, time-stamped clinical notes for every 30-minute block.
Common Clinical Scenarios
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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