Principal care management CPT codes 99424 to 99427

The 99426 CPT code description covers the first 30 minutes of directed clinical staff principal care management, or PCM, each calendar month. PCM focuses on one high-risk chronic condition expected to last at least three months, with significant risk of hospitalization, acute worsening, functional decline or death.

The first coding distinction is who performs the care. A practice should select the clinical-staff or practitioner-personal pathway from the documented service, then confirm the disease-specific plan, consent and other payment requirements.

99426 CPT code description and the other PCM codes

The four principal care management CPT codes separate the base service from additional time, and clinical staff work from personally furnished practitioner work. Use the descriptor for the person performing care, rather than selecting a code from the diagnosis alone.

Code	Who performs the time	Time described	Pairing
99426	Clinical staff directed by physician or other qualified health professional	First 30 minutes	Clinical-staff base service
99427	Directed clinical staff	Each additional 30 minutes	Add-on to 99426
99424	Physician or other qualified health professional personally	First 30 minutes	Practitioner-personal base service
99425	Physician or other qualified health professional personally	Each additional 30 minutes	Add-on to 99424

A base-code threshold and an add-on threshold answer different questions. As an illustration, 60 qualifying clinical-staff minutes contain the first 30-minute increment and one additional 30-minute increment; the clinical service must still meet the PCM requirements.

Do not substitute the personal-time codes for staff activity because the practitioner directed it. Direction of staff and personally performing the service are distinct roles in the code descriptions.

99426 CPT code description: which patient and plan fit

PCM concerns a single high-risk chronic condition, not simply any condition appearing on the problem list. The duration and significant-risk criteria must be part of the practitioner’s clinical assessment.

• Identify the condition the PCM service will manage.
• Confirm the expected duration of at least three months and the significant clinical risk.
• Develop, monitor or revise the disease-specific care plan.
• Document ongoing communication and coordination with other practitioners involved in care.

Disease-specific means the plan is focused on the condition being managed. It does not mean the team can ignore other treating practitioners; CMS requires the practitioner billing PCM to document ongoing communication and care coordination in the medical record.

For a reader new to the term, the PCM medical abbreviation guide explains the program language. For the broader choice between programs, the PCM versus CCM comparison addresses condition focus and how the plans differ.

Start PCM with an initiating visit and informed consent

The visit and consent are both necessary

The CY2020 final rule states that both the initiating visit and the patient’s verbal consent are necessary. The practice must explain PCM and any cost sharing that may apply, then document the consent in the medical record.

A patient meeting the clinical criteria may still decline the service. Eligibility is the practitioner’s assessment; participation requires the patient’s informed agreement.

Keep the PCM consent discussion specific to the condition-focused service being proposed. Record what the patient was told about possible cost sharing and the patient’s agreement, so the record distinguishes informed consent from a diagnosis-based eligibility assessment.

Plan for the CMS continuation requirement

The CMS CCM booklet says: “After 1 year, we require another initial visit to continue the services.” Build a reminder into the practice workflow so continuing monthly work does not obscure this visit requirement.

The booklet also says PCM may be provided monthly when the patient needs it and cannot be billed for less than 30 minutes per calendar month. An ongoing diagnosis does not by itself establish a new monthly service.

How to review a PCM calendar month

1. Begin with the disease-specific plan

Ask the clinical team what changed, what remained unresolved and what care coordination occurred for the condition. These are practical review prompts for the practice, rather than a new CMS form or a separate reimbursement requirement.

The record should allow the billing practitioner to connect the service to the disease-specific plan. A disconnected time total does not explain the clinical work that the practice proposes to report.

2. Identify the performer and supervision arrangement

The clinical-staff PCM pathway permits general supervision. The personal-time pathway describes work personally furnished by the physician or other qualified health professional; supervising staff does not change staff minutes into personal minutes.

For the practice’s operational agreement, identify who performs the work, who directs clinical care and who reviews the billing record. Which team members’ time counts toward each code is set in your services agreement.

3. Reconcile the service and time

1. Confirm that the patient still needs the condition-specific monthly service.
2. Review the initiating visit and documented consent information.
3. Reconcile the calendar-month time by the applicable personnel pathway.
4. Check separately billed work for overlapping time and incompatible services.
5. Have the billing practitioner resolve clinical questions before the billing team submits.

An add-on extends the base service; it does not create another condition-specific program for the same work. If the record does not clearly distinguish the staff and personal services, return it for clarification instead of assuming that every minute belongs in one combined total.

4. Keep coordination visible

When another practitioner manages a different condition, document the communication between the teams. This matters especially when PCM and another care-management program appear in the same patient’s monthly record.

PCM beside CCM, APCM and navigation services

The same practitioner cannot bill PCM and chronic care management for the same patient in the same month. Different practitioners may furnish them for different conditions; CMS says two care plans are required, with the PCM plan remaining disease-specific.

For example, a specialist may furnish PCM while a primary care practitioner furnishes CCM for different conditions. The permission depends on the practitioner and condition distinctions, not simply the fact that the patient sees two offices.

The practitioner billing advanced primary care management cannot also bill PCM for that patient in the same month. A different practitioner may furnish a medically necessary separately billable service, including within the same practice.

Principal illness navigation and community health integration may be furnished alongside other care-management services when requirements are met, the services are reasonable and necessary, and time and effort are not counted twice. Keep the qualifying work separate rather than treating the programs as interchangeable names for one activity.

PCM code misreadings to resolve before submitting

Do not import an additional-code reporting limit from a company article or another program. This guide does not establish a monthly frequency cap for the PCM add-ons; confirm current claim edits and any unusual billing scenario with your MAC.

Do not make a blanket patient-cost promise. The final-rule wording is to educate the patient about PCM and “any cost sharing that may apply”; explain that during consent rather than assigning a universal amount.

Do not treat an outsourcing arrangement as the billing entity. Your practice remains the party choosing and submitting the claim under its own license, with clinical questions routed to the billing practitioner.

Agree the people and records before monthly care starts

When evaluating principal care management services, start with the patient group, disease-specific plans and the record your billing team needs. Which team members’ time counts toward each code is set in your services agreement.

Companian: “Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.”

Key takeaways

• 99426 is the clinical-staff PCM base code for the first 30 minutes per calendar month.
• 99427 describes each additional 30 minutes of directed clinical staff time.
• 99424 and 99425 describe personally furnished practitioner PCM.
• PCM requires a disease-specific plan and documented coordination with other practitioners.
• The same practitioner cannot report PCM and CCM for the same patient in the same month.

Frequently asked questions about 99426 cpt code description

Which PCM codes describe staff time rather than personal practitioner time?

99426 and 99427 describe directed clinical staff time. 99424 and 99425 describe work personally furnished by the physician or other qualified health professional.

Does PCM always need a comprehensive multi-condition care plan?

PCM uses a disease-specific care plan for the condition being managed. CMS also requires documentation of ongoing communication and coordination among relevant practitioners.

Can less than 30 monthly minutes support PCM billing?

CMS says PCM cannot be billed for services of less than 30 minutes per calendar month. The practice must also meet the applicable clinical and service requirements.

What does CMS say about the visit after a year of PCM?

The CMS booklet states, “After 1 year, we require another initial visit to continue the services.” The practice should track that requirement alongside its monthly service review.

Can two practitioners furnish PCM and CCM for different conditions?

CMS permits different practitioners to furnish PCM and CCM for different conditions concurrently. Two care plans are required, with the PCM plan focused on its disease.

Can directing staff convert 99426 work into 99424 personal time?

No, the descriptions distinguish directed clinical staff time from personally furnished practitioner time. Select the pathway from the service and performer documented in the record.

Medicare Part B principal care management uses CPT 99426 and 99427 for directed clinical-staff care and 99424 and 99425 for personally furnished practitioner care in physician practices. Companian: “Your team refers; we handle enrollment, outreach and documentation. You bill monthly under your license.”

Read more: PCM and CCM comparison · PCM terminology

Rates & disclosures

National amounts are 2026 Medicare Physician Fee Schedule non-facility payments at the non-QP conversion factor of $33.4009, computed from CMS RVUs. Your amount depends on your Medicare payment locality; see it in the CCM/PCM revenue calculator. Actual payment depends on participation status, place of service and cost-sharing.

This guide summarizes CMS rules for practices nationwide and is not legal or billing advice. Sources:

• CMS MLN909188, Chronic Care Management Services
• CY 2026 Physician Fee Schedule final rule (CMS-1832-F)
• CMS 2026 Physician Fee Schedule relative value files (RVU26D)
• CMS, Health-Related Social Needs FAQ