CPT 99426
Description, Billing Rules, and Use Cases
CPT 99426 is used to bill for Principal Care Management (PCM) services delivered by clinical staff under the supervision of a physician or other qualified healthcare professional.
This code covers the first 30 minutes of care management in a calendar month for a patient with a single high-risk condition that requires a disease-specific care plan.
Services may include communication with the patient or caregiver, medication management, care coordination, and ongoing clinical monitoring.
What is CPT Code 99426?
CPT 99426 is a time-based billing code for 30 minutes of care management services performed by clinical staff, under the direction of a physician or qualified healthcare professional (QHP), for a single complex chronic condition. The condition must:
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Be expected to last at least 3 months
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Place the patient at significant risk of hospitalization, exacerbation, functional decline, or death
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Require frequent medication adjustments or unusually complex care due to comorbidities
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Require a specific care plan that is revised or monitored during the billing period
This code covers services such as:
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Disease-specific care planning
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Medication regimen management
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Communication with other practitioners
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Coordinating referrals or community services
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Educating the patient or caregiver about the condition and self-management
CPT 99426 must be used for the first 30 minutes of clinical staff time each month. If additional time is spent, use CPT 99427 for each additional 30-minute block.
CPT 99426 Billing Requirements and Eligibility
CPT 99426 is used to report Principal Care Management (PCM) services provided by clinical staff under the supervision of a physician or qualified healthcare professional (QHP).
These services must address a single serious chronic condition and meet specific care coordination and time documentation standards.
Patient Eligibility Criteria
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The patient has one 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, functional decline, or death
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Requires frequent medication adjustments or intensive care coordination
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The condition must be the focus of care for the month
Care Plan Requirements
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A disease-specific care plan must be:
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Established, implemented, revised, or monitored during the billing month
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Focused on managing the targeted condition
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Documented in the patient’s medical record
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The plan must include:
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Goals, interventions, expected outcomes, and clinical monitoring
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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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The PCM services must be delivered by clinical staff under direct supervision
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The provider must oversee and direct the care plan and review staff-delivered services
Service Requirements
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At least 30 minutes of clinical staff time must be spent delivering PCM services in a calendar month
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Activities must be non-face-to-face and may include:
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Medication management
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Communication with other providers
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Patient or caregiver education
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Referrals and service coordination
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Time must be:
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Distinct from other billed services (e.g., CCM, TCM, BHI)
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Accurately logged and documented for each activity
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CPT 99426 Billing Documentation Checklist
To support compliant billing for CPT 99426, your records should include the following:
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A clear record of 30 minutes or more of care management services delivered by clinical staff under provider supervision
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Include exact time logs with dates, activities performed, and total duration
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A disease-specific care plan that was:
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Established, implemented, revised, or monitored during the month
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Targeted to a single chronic condition
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Documented in the medical record and shared with the patient or caregiver when appropriate
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Documentation that the patient’s condition:
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Is expected to last at least 3 months
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Poses significant health risk or care complexity
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Was the primary focus of care during the billing period
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Description of care management activities such as:
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Medication reconciliation or adjustment
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Coordinating with specialists or service providers
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Educating the patient or caregiver about disease-specific management
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Communicating with the patient or caregiver between visits
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A note that time reported:
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Was non-face-to-face
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Did not overlap with time billed under any other code, including:
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CCM (99490–99491)
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Complex CCM (99487–99489)
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PCM (99424–99425)
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TCM or BHI services
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Provider attestation or oversight statement confirming they directed the care plan and supervised the services delivered by staff
CPT 99426 Time Thresholds and Code Combinations
CPT 99426 is used to report the first 30 minutes of Principal Care Management (PCM) services provided by clinical staff under the supervision of a physician or qualified healthcare professional. If care management activities exceed 30 minutes in a calendar month, use CPT 99427 to report each additional 30-minute block of time.
Use the table below to determine the correct code(s) to report based on the total time spent delivering PCM services:
Important to Note:
CPT 99426 may only be billed for clinical staff time provided under the supervision of a physician or other qualified healthcare professional. It must reflect care management for a single complex chronic condition, not general wellness or multiple conditions.
Use CPT 99427 for each additional 30-minute block beyond the initial 30 minutes. Time must be clearly documented, non-overlapping with other codes, and delivered outside of face-to-face E/M services.
When to Use CPT 99426:
Common Scenarios and Use Cases
CPT 99426 is appropriate when clinical staff spend at least 30 minutes in a calendar month managing care for a patient with one serious chronic condition. This work must be directed by a physician or qualified healthcare provider and focused on a disease-specific care plan.
Here are examples of how CPT 99426 is used in practice:
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Asthma Management for High-Risk Adolescent
Clinical staff allocates time to:-
Communicate with family weekly
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Coordinate prescriptions and inhaler refills
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Reinforce education on proper medication technique
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Total time: 35minutes
Billing: 99426
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Post-Hospital Hypertension Monitoring
Staff under physician supervision:-
Monitors blood pressure logs remotely
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Calls patient to review medication adherence
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Updates care plan in response to changes
Total time: 55minutes
Billing: 99436
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Heart Failure Self-Management Support
Clinical Staff:-
Provides education on dietary sodium control
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Coordinates cardiology follow-up
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Monitors symptoms and document changes weekly
Total provider time: 65 minutes
Billing: 99426 + 99427
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Common CPT 99426 Billing Mistakes
(and How to Avoid Them)
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❌ Billing Without 30 Minutes of Documented Staff Time
CPT 99426 requires a minimum of 30 minutes of qualifying clinical staff time per calendar month. Anything less is not billable, even if services were medically appropriate.
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❌ Using 99426 for Multiple Conditions
PCM codes, including 99426, are intended for the management of a single high-risk chronic condition. If multiple conditions are being managed, consider Chronic Care Management (CCM) codes instead.
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❌ Billing Without a Disease-Specific Care Plan
A documented care plan tailored to the specific condition is required. Generic templates or general wellness plans do not satisfy this requirement.
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❌ Overlapping With Other Time-Based Codes
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You may not bill CPT 99426 in the same month as:
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99490 or 99491 (CCM)
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99487 or 99489 (complex CCM)
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99424 or 99425 (provider PCM)
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Transitional or behavioral integration codes (99495–99496, 99484, 99492–99494)
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All time must be distinct and dedicated to the qualifying PCM activity.
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❌ Insufficient Documentation of Staff Activity
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You must include:
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Specific time logs with start/stop times or cumulative entries
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Clear descriptions of services provided
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Evidence of physician/QHP supervision and care plan oversight
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