CPT 99425
Description, Billing Rules, and Use Cases
CPT 99425 is an add-on billing code used to report each additional 30 minutes of Principal Care Management (PCM) services personally delivered by a physician or qualified healthcare professional (QHP).
This code is billed in conjunction with CPT 99424, which covers the initial 30 minutes of provider time. CPT 99425 may be reported multiple times per month when care extends beyond 60, 90, or 120 minutes, provided time thresholds are met and services are documented appropriately.
What is CPT Code 99425?
CPT 99425 is used to report each additional 30-minute block of provider-delivered Principal Care Management services for patients with a single serious chronic condition. It is an add-on code that must be reported with CPT 99424, which covers the first 30 minutes of non-face-to-face provider time.
Use CPT 99425 when:
The patient has one chronic condition expected to last at least 3 months
The condition presents a significant risk of hospitalization, functional decline, or death
The provider has already delivered at least 30 minutes of care (reported as 99424)
An additional 30-minute increment is completed and clearly documented
Services involve moderate or high complexity decision-making
The time is personally provided by the billing physician or QHP, not clinical staff
CPT 99425 cannot be billed as a standalone code and may not be used in the same calendar month as staff-based PCM (99426–99427), CCM, or complex CCM codes.
CPT 99425 Billing Requirements and Eligibility
CPT 99425 is an add-on code used to report each additional 30-minute block of Principal Care Management (PCM) services personally delivered by a physician or qualified healthcare professional (QHP). This code must be billed in conjunction with CPT 99424, which covers the first 30 minutes.
Patient Eligibility Criteria
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The patient has one serious chronic condition that:
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Is expected to last at least 3 months
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Poses a significant risk of hospitalization, exacerbation, or functional decline
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Requires disease-specific care coordination, frequent medication adjustments, or intensive monitoring
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The condition is the primary focus of care during the calendar month
Care Plan Requirements
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A disease-specific care plan must be:
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Created, revised, or actively managed during the billing month
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Focused entirely on the single chronic condition being treated
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Documented in the patient record with measurable goals and interventions
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Shared with the patient or caregiver when appropriate
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Provider Requirements
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The billing provider must be a physician, nurse practitioner, or physician assistant
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Services must be delivered personally by the provider
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Time cannot be delegated to clinical staff
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CPT 99425 must be billed with CPT 99424 in the same calendar month
Service Requirements
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CPT 99425 can be billed once total provider time reaches 60 minutes
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99424 covers the first 30 minutes
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Each 99425 unit represents an additional 30 minutes
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Activities may include:
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Medication titration and management
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Care coordination with other providers
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Direct communication with the patient or caregiver
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Review of labs or diagnostics related to the care plan
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Services must be:
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Non-face-to-face
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Distinct from time billed under any other PCM, CCM, or TCM codes
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Supported by clear documentation of time, decision-making, and condition-specific care
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CPT 99425 Billing Documentation Checklist
To support clean and compliant billing for CPT 99425, the following must be clearly documented in the patient record:
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Confirmation that CPT 99424 has already been billed for the same calendar month
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CPT 99425 may not be billed as a standalone code
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Documentation of 60 or more total minutes of non-face-to-face time personally delivered by the billing provider
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Each unit of 99425 requires an additional 30-minute block beyond the first 30 minutes
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A clear, disease-specific care plan that was:
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Created, implemented, revised, or actively monitored during the billing period
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Focused on a single high-risk chronic condition
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Documented in the patient record and available for audit
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Detailed activity notes for the additional time blocks, including:
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Care coordination and communication with external providers
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Review of diagnostics and treatment response
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Patient or caregiver coaching and clinical monitoring
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Updates to medications, labs, or clinical goals
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A statement confirming that:
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The care was personally provided by the billing provider
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All time was non-face-to-face
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Time was distinct from any other billed care management codes (e.g., 99426–99427, 99490–99491, 99487–99489)
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CPT 99425 Time Thresholds and Code Combinations
CPT 99425 is an add-on billing code used to report each additional 30 minutes of Principal Care Management services personally delivered by a physician or qualified healthcare professional (QHP). This code must be reported with CPT 99424, which covers the first 30 minutes. CPT 99425 may be billed multiple times in a calendar month, depending on the total provider time spent managing a single chronic condition.
Use the table below to determine the correct code(s) to report based on total provider time:
Important to Note:
CPT 99425 may only be billed when CPT 99424 has also been reported. Each additional unit of 99425 represents an extra 30-minute block of provider time and may not include time performed by clinical staff.
All billed time must be:
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Personally performed by the billing provider
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Focused on one high-risk chronic condition
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Clearly documented, with activities and time logs
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Non-overlapping with other time-based codes (e.g., CCM, PCM staff codes, TCM)
When to Use CPT 99425:
Common Scenarios and Use Cases
CPT 99425 should be used when a physician or qualified healthcare professional provides more than 60 minutes of non-face-to-face Principal Care Management (PCM) services in a single calendar month. This code must be billed in addition to CPT 99424, which covers the first 30 minutes of provider time.
Here are examples of how CPT 99425 is used in practice:
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Provider Oversight of Treatment Plan for ALS
A neurologist:-
Reviews multiple rounds of specialist input
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Revises disease-modifying therapy plan
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Communicates with home health and caregiver team
Total time: 75 minutes
Billing: 99424 + 99425
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Complex Pain Management for Sickle Cell Anemia
A hematologist:-
Conducts recurring medication reviews and adjustments
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Coordinates with hematology and pain management
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Updates opioid agreement and care goals
Total time: 95 minutes
Billing: 99424 + 99425 x2
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High-Risk Cardiac Patient Post-Discharge
A cardiologist:-
Communicates with DME provider and care manager
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Reviews labs and imaging
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Makes multiple modifications to the patient’s anticoagulation and CHF medication strategy
Total provider time: 125 minutes
Billing: 99424 + 99495 x3
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Common CPT 99425 Billing Mistakes
(and How to Avoid Them)
CPT 99425 is a provider add-on code and comes with strict billing and documentation expectations. Watch for these frequent issues:
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❌ Billing CPT 99425 Without CPT 99424
CPT 99425 is an add-on code and cannot be billed on its own. It must appear alongside CPT 99424 in the same calendar month and claim.
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❌ Reporting Fewer Than 60 Minutes of Total Provider Time
The first 30 minutes must be billed with 99424. You may only bill 99425 if at least 60 minutes of provider-delivered PCM services are documented.
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❌ Using 99425 for Clinical Staff Time
This code applies only to services personally delivered by a physician or QHP. Clinical staff time must be reported under CPT 99426/99427, not 99425.
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❌ Overlapping Time With Other Care Management Codes
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❌ Insufficient Documentation of Additional Time
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You must clearly record:
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The total time spent beyond the first 30 minutes
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Specific provider-led care activities during that time
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A continued focus on the same qualifying chronic condition
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Non-face-to-face delivery of all services
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