Summary & Overview
CPT 99425: Additional Chronic Care Management Time (30-Min Increments)
CPT code 99425 represents additional time-based physician or qualified healthcare professional services for managing complex chronic conditions. It applies when a patient’s condition is expected to last at least three months and places the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. The code covers each additional 30 minutes of clinician time beyond the first 30 minutes in a calendar month, supporting intensive care planning and longitudinal management for high-risk patients.
This publication addresses national implications of using CPT code 99425 across major payers: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the code’s clinical intent, typical service settings, and the policy and billing context relevant to these payers. The analysis summarizes common billing patterns and documentation expectations, highlights common modifiers used with time-based chronic care services, and outlines areas where policy updates or payer-specific rules may influence reimbursement and care delivery.
Intended for clinicians, practice managers, and coding professionals, the report explains when CPT code 99425 is appropriately applied, what elements drive correct capture of additional clinician time, and where to look for payer-specific policy guidance. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 99425 describes management and care plan services personally performed by a physician or other qualified healthcare professional for a patient with a complex chronic condition expected to last three months and placing the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. The code is used for each additional 30 minutes of physician or other qualified healthcare professional time beyond the first 30 minutes in a calendar month.
Service type: Chronic care management and care plan services
Typical site of service: Outpatient or ambulatory care settings, including clinic visits and practice-based care coordination activities
Clinical & Coding Specifications
Clinical Context
A 72-year-old patient with long-standing congestive heart failure with reduced ejection fraction, chronic kidney disease stage 4, and insulin-dependent diabetes is enrolled in a complex chronic care management program. During a month in which the patient experiences worsening dyspnea, increased peripheral edema, and recurrent nocturnal hypoglycemia, a cardiologist or other qualified healthcare professional personally delivers an additional 45 minutes of directed management and care plan services beyond the first 30 minutes. The encounter includes review of the patient’s medications, recent hospital discharge summary, laboratory and imaging results, reconciliation with the primary care team, modification of diuretic dosing, coordination with home health nursing for daily weights, and documentation of goals of care and advance directives.
The clinical workflow: the clinician reviews incoming records and diagnostic data, conducts synchronous or asynchronous communication with the patient and caregivers, documents time spent on complex decision-making and care coordination in the medical record, and bills 99425 for the additional 30-minute increment in the same calendar month after the initial 30 minutes of qualifying care time have been met. Typical touches include phone or secure portal communication, multidisciplinary case conferences, and directed coordination with pharmacy and home health services. The typical site of service is an outpatient clinic, physician office, or other non-facility ambulatory setting where longitudinal chronic care management is delivered.
Coding Specifications
- The following modifiers are the most clinically relevant to
99425and guidance on their use are summarized below.
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