CPT Code 99424: Under Principal Care Management Services

What is CPT code 99424?

CPT code 99424 covers principal care management (PCM) services delivered personally by a physician or another qualified healthcare professional. This service is specifically intended for patients with a single complex chronic condition expected to persist at least three months, placing them at significant risk of hospitalization, functional decline, or death.

The principal care management CPT code 99424 is reported for the first 30 minutes of PCM clinical staff time in a calendar month and includes services such as medication management, frequent adjustments of treatment plans, coordination with clinical staff, and continuous monitoring.

Eligible billing practitioners include physicians, nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists, providing a critical bridge between traditional office visits and intensive chronic care management (CCM).

What is principal care management?

Principal care management (PCM) involves focused management of a single, complex chronic condition, requiring significant healthcare professional attention due to its high risk of acute exacerbation or functional decline.

PCM services include creating and revising care plans, frequent adjustments to medication regimens, patient education, remote patient monitoring (Medicare-approved), and coordination with clinical staff. Conditions commonly managed with PCM include congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, and Parkinson’s disease.

CPT code 99424 documentation guidelines

Accurate documentation for billing CPT code 99424 must reflect thorough and detailed PCM services:

Diagnosis and duration of the condition

Clearly document the specific diagnosis being managed and note that the condition is expected to persist for at least three months.

Evidence of moderate to high risk

Document clearly that the patient faces a significant risk of hospitalization, acute exacerbation, functional decline, or death if the condition is not intensively managed.

Care plan creation and revisions

Include notes describing the establishment of the care plan and any subsequent modifications or frequent adjustments necessary due to the patient’s condition.

Time spent providing PCM services

Maintain a detailed log indicating at least 30 minutes per calendar month spent directly providing PCM services by a physician or qualified healthcare professional.

Non-face-to-face activities

Document thoroughly all non-face-to-face management activities, including medication regimen adjustments, patient or family communications, remote patient monitoring activities, and care coordination tasks with clinical staff.

CPT code 99424 billing guidelines

Correct billing for CPT 99424 involves adhering to specific guidelines:

Monthly billing frequency

Bill CPT 99424 only once per calendar month per patient, capturing the initial 30 minutes of principal care management services provided.

Use with add-on code 99425

For additional PCM clinical staff time beyond the initial 30 minutes per month, report add-on CPT code 99425 for each additional 30-minute increment.

Patient consent required

Document clear patient consent before initiating PCM services, as required for all principal and chronic care management services.

Concurrent billing limitations

CPT 99424 cannot be billed concurrently with chronic care management (CCM) codes (such as 99490 series) for managing the same condition in the same month.

Modifiers applicable to CPT code 99424

Modifiers help clarify the circumstances under which CPT code 99424 is reported. Modifiers are not mandatory by default but may be required based on payer guidelines and specific clinical scenarios. Always verify individual payer policies for modifier usage.

• Modifier GC – Resident involvement: Indicates services partially performed by a resident under a teaching physician's supervision.
• Modifier SA – Nurse practitioner collaboration: Shows the service was rendered by a nurse practitioner working collaboratively with a physician.
• Modifier U7 – State-specific or payer-specific modifier: Used to fulfill certain state Medicaid requirements or payer-specific scenarios.
• Modifier 24 – Unrelated evaluation and management service: Used if an unrelated E/M service occurs during a postoperative period.
• Modifier 25 – Significant, separately identifiable E/M service: Applied if a distinct E/M service occurs on the same day as PCM services.
• Modifier 57 – Decision for surgery: Indicates the PCM service led directly to the decision for surgery.
• Modifier 99 – Multiple modifiers: Indicates multiple modifiers apply to a single PCM service.

Related CPT codes

The following primary care management CPT codes are related to CPT code 99424:

• 99425 – PCM add-on code, each additional 30 minutes per month
• 99426 – PCM by clinical staff, initial 30 minutes monthly
• 99427 – PCM by clinical staff, add-on for each additional 30 minutes monthly
• 99490 – Chronic care management (CCM) services, initial 20 minutes monthly
• 99491 – CCM provided personally by physician or other qualified healthcare professional, minimum 30 minutes monthly