Reimbursement
$45.42
Threshold
30m
2026 Status
Active
What is CPT Code 99427?
CPT 99427 is defined as: Principal care management services, for a single high-risk disease, 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).
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)
1.28
Practice Expense
Malpractice
0.03
Risk Factor
Total RVU
1.36
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).
stacking efficiency
Staff PCM add-ons ($48.43) allow specialist practices to capture the true cost of complex case management that exceeds the initial 30-minute block.
fqhc rhc transition
FQHCs can now scale staff-led PCM billing using 99427 units for high-intensity cases, moving away from flat G0511 rates.
Administrative Framework
Operational Requirements
minimum time
Each additional 30 minutes (Threshold starts at 60 total aggregate staff minutes).
primary code
99426 (Must be billed for the first 30 minutes).
frequency
Multiple units allowed per calendar month.
supervision
General supervision by Physician/QHP.
Compliance Checklist
Audit Defense
time integrity
Audit defense relies on specific, non-repetitive descriptions of interventions (e.g., avoid 'called patient' generic notes; use 'reviewed lab result XYZ and adjusted dose per protocol').
threshold verification
Ensure aggregate time actually hits the 60, 90, 120 mark before billing additional units.
2026 Update
Medicare audits focus on 'cloned' documentation across multiple units. Each unit must represent unique, medically necessary clinical work.
Common Clinical Scenarios
Target Specialties & Utilization
Typical Clinical Indications (ICD-10)
Frequently Asked Questions
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