Chronic Care Management (CCM) services require coordination between physicians, reviewing reports, monitoring the plan of care, and much more. The services are challenging to deliver, but their billing is more demanding. Luckily, things have gotten easier over the past few years. Now, more precise and detailed billing codes for CCM have been added to the CPT codes list.
One of these codes is CPT code 99426. We have created this detailed guide on 99426 to help you understand how to use this code effectively in your claims. So, let’s start.
CPT Code 99426 – Description
CPT code 99426 is a principal care billing code. It replaced the HCPCS code G2065 in 2022. The new code describes principal care management services provided by clinical staff under the direct supervision of a physician or qualified healthcare professional for the first 30 minutes per calendar month.
The phrases “clinical staff” and “first 30 minutes” are vital to note here. Many billers confuse this code with code 99424, which refers to principal care services provided by a physician. For 99426 to be valid, the care services must be provided by the clinical staff, not the physician.
Additionally, code 99426 should only be used to bill the first 30 minutes of services. If the service extends more than 30 minutes, the CPT code 99427 must be used. Another essential point worth mentioning here is that 99426 includes care for a single high-risk disease expected to last at least 3 months, and can be used once a month.
Scenarios Where CPT Code 99426 is Applicable
Let’s discuss some appropriate examples to better understand the practical use of CPT code 99426:
Diabetes Management
For our first scenario, we will discuss the case of a diabetic patient.
Suppose a patient has type 1 diabetes. He visits his physician every month. The patient requires frequent insulin adjustments, continuous glucose monitoring interpretation, and coordination between endocrinology and primary care.
To meet all these requirements and manage complex coordination, the clinical staff spends 30 minutes measuring and reviewing blood glucose logs and adjusting medication under the supervision of the physician. The staff also educates the patient on how to manage his carbohydrate intake.
In this scenario, the services provided by the clinical staff can be billed via CPT code 99426.
Chronic Kidney Disease
Now, suppose a man has stage 4 chronic kidney disease. To keep the disease under control, he requires routine monitoring and changes in the medication. So, he visits his nephrologist once a month. The patient requires frequent lab monitoring, dietary modifications, and coordination between his nephrologist and primary care physician.
All these services are performed by the clinical staff within 30 minutes under the supervision of the prescribing physician. So, in this case, the services can be billed via CPT code 99426.
CPT Code 99426 – Billing & Reimbursement Guidelines
The following are some essential points to consider to improve your claims acceptance rate.
Provide Detailed Documentation
Like every other billing code, documentation is vital to prevent CPT code 99426 denials. We suggest you add the following details to your claims:
- Disease-specific care plan created, implemented, revised, or monitored.
- Time logs showing at least 30 minutes of qualifying clinical staff activities.
- Evidence of physician supervision and direction of care management activities.
- Documentation that services addressed a single high-risk chronic condition.
- Proof that the condition meets the three-month duration and risk criteria.
Keep in Mind the Billing Frequency
You should only bill CPT code 99426 once every month. Moreover, if the principal care management services exceed 30 minutes, append CPT code 99427 to the bill for the additional time.
Verify the Medicare Reimbursement Rate
According to the latest Medicare Physician Fee Schedule, the national average reimbursement for CPT code 99426 is $61.78 in non-facility settings and $47.55 in facility settings.
However, this rate varies significantly for each Medicare Administrative Contractor (MAC) locality. You can check the exact amount for your MAC via the PFS Lookup Tool.
Wrapping Up
Let’s conclude our guide here. CPT code 99426 is a principal care management code, used to bill the services provided by the clinical staff. To avoid denials, you must append the relevant documentation, check for frequency limitations, and follow the guidelines that we mentioned in this blog.
However, if you are facing difficulty filing your claims or frequent denials, let our professionals handle the hard work. Our billing consultants at MediBillMD offer expert CCM billing services at competitive rates.
