Reimbursement
$63.46
Threshold
30m
2026 Status
Active
What is CPT Code 99426?
CPT 99426 is defined as: Principal care management services, for a single high-risk disease, first 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. This service is for patients with one complex chronic condition requiring disease-specific coordination and management.
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
0.05
Physician Effort
PE (Non-Fac)
1.81
Practice Expense
Malpractice
0.04
Risk Factor
Total RVU
1.9
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).
specialization premium
Staff-led PCM ($63.13) pays slightly more than CCM ($61.96 for 99490), reflecting the focused intensity of single-disease expertise.
fqhc rhc transition
FQHCs must now transition from G0512/G0511 to itemized 99426 billing for staff-led PCM and capturing the 30-minute threshold.
Administrative Framework
Operational Requirements
minimum time
30 minutes of cumulative clinical staff time per calendar month.
condition count
Single high-risk chronic condition ONLY.
frequency
Once per calendar month.
supervision
General supervision by Physician/QHP ('incident-to').
Compliance Checklist
Audit Defense
disease focus
Audit records must show interventions specifically for the primary high-risk disease. Generalized care should be billed as CCM instead.
no double billing
Cannot bill CCM 99490 and PCM 99426 for the same patient in the same month.
2026 Update
A common audit failure is billing PCM for stable, low-risk single conditions. Documentation must show 'high-risk' status (expectancy of hospitalization).
Common Clinical Scenarios
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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