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CPT – 99426

“CPT Code 99426 covers the first 30 minutes of PCM clinical staff time, as carried out by clinical staff (such as nursing professionals), under the direction and guidance of a physician or QHP. It is an expansion of what was earlier available under G2064.”

CATEGORY

Principal Care Management Services for a Single High-risk Disease

CODE TYPE

Time Based Code – Billed for the first 30 Minutes of Clinical Staff Time

ADD-ON CODE

For each additional 30 minutes of clinical staff time, see cpt-99427.

PRINCIPLE CARE MANAGEMENT

PRINCIPAL CARE CPT CODE – 99426 is Billed to the Patient when the Clinical staff members, directed by a physician or other qualified healthcare professional, perform management and care plan services for a patient with a complex chronic condition expected to last three months, which places the Patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. Use this code for the first 30 minutes of clinical staff time per calendar month.

CODING CRITERIA

For CPT 99426, the following criteria should be met;

  • 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 deat
  • Development, monitoring, or revision of a disease-specific care plan
  • Ongoing communication and care coordination between relevant practitioners furnishing care
  • First 30 minutes of clinical staff time directed by the physician or other qualified health care professional per calendar month.
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BILLING CRITERIA

CPT code 99426 can be billed once per calendar month for the first 30 minutes of clinical staff time when directed by a physician or other QHP.

ADD ON CODE:

In case of service provided for each additional 20 minutes, use CPT code 99427.
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CPT – 99426

CPT – 99426 “CPT Code 99426 covers the first 30 minutes of PCM clinical staff time, as carried out by clinical staff (such as

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