Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • NPI Medicare & Medicaid
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerBilling CodesPrincipal Care Management ServicesCPT cpt-99425-chronic-care-management-additional-30-min
    Ask Trek AI about this page

    CPT 99425: Complex Chronic Care Management, Additional 30 Minutes

    Medicare pays $63 on average nationally for this procedure.

    CPT code 99425 describes physician or other qualified healthcare professional management and care plan services 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; this code is for each additional 30 minutes of clinician time beyond the first 30 minutes in a calendar month, typically delivered as complex chronic care management in ambulatory or outpatient settings and involving care coordination, longitudinal management, and structured care planning.

    For related coverage guidance, see recent payer policy updates: Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure, Cardiology - Ivabradine, Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA).

    Customize your policy alerts

    Sign up for cpt 99425 policy alerts

    Get alerted when payer policies referencing 99425 are released or updated.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    Table of contents

    Progress1 / 6

    Explore openpayer tools

    • Billing CodesCPT, HCPCS, DRG & more
    • Reimbursement RatesCommercial vs. Medicare rate reports
    • Facility ComparisonBeds, revenue & payer mix
    • ProvidersHospitals & facilities
    • PayersPlans & market footprint
    • Taxonomy CodesNUCC specialty codes
    • ModifiersCPT modifiers & usage
    • Prior AuthorizationPA policies by payer & drug
    • Timely FilingFiling deadlines by payer
    • Coverage CriteriaMedical necessity by payer
    • Payer ContactsClaims, PA & appeals contacts
    View all tools

    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.

    Related CPT Codes

    • When specific related CPT codes were not provided, the following commonly performed services are frequently associated with chronic care management workflows.
    CPT CodeDescriptionRelationship to This Procedure
    99490Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar monthOften billed for non-physician CCM time; used for baseline monthly CCM when physician-level time is not required
    99439Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health professional per calendar monthUsed to report additional non-physician CCM time increments beyond the base 99490
    99424A physician or other qualified healthcare professional personally performs management and care plan services for a patient with a complex chronic condition, first 30 minutes in a calendar monthBilled for the initial 30 minutes of physician-level complex chronic care management; 99425 is used for subsequent 30-minute increments
    99426Data not available in the input.
    99091Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient to the physician or other qualified healthcare professional, 30 minutes

    Related Modifiers

    7 rows

    ModifierDescriptionWhen to Use
    25CPT modifier 25 indicates that on the same day as another procedure or service, the same physician or other qualified health care professional provided a significant, separately identifiable…- When to apply: Use modifier 25 only on an E/M code to indicate the same provider delivered a significant, separately identifiable E/M service on the same day as another procedure or service — i.e.,…
    22Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
    52Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
    53Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
    62Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…
    78CPT modifier -78 indicates an unplanned, related return to the operating or procedure room by the same provider during the global postoperative period. It is appended when treatment for a…- Use modifier -78 when an unplanned, related complication during the original procedure’s global postoperative period requires the patient to return to a formal operating or procedure room and the…
    80CPT® Modifier 80 (Assistant Surgeon) is appended to a surgical CPT code when a physician (MD or DO) provides full, continuous assistance throughout the operative procedure. It is intended only for…- Use CPT Modifier -80 when a physician (MD or DO) serves as an assistant surgeon and provides full, continuous assistance throughout the entire operative procedure; append -80 to the surgical CPT…

    Related Provider Taxonomies

    8 rows

    Taxonomy Code
    207RC0000X
    207L00000X
    207Q00000X
    2084P0800X
    363LF0000X
    374T00000X
    2084A2900X
    103K00000X

    Related Payer Policy Updates

    Specialty: Cardiology1 / 3

    10 rows

    PolicyPayerEffective Date
    Automated Ambulatory Blood Pressure Monitoring for Diagnosis of Hypertension in Patients with Elevated Office Blood PressureBluecross Idaho2026-11-01
    Cardiology - IvabradineCigna2026-10-15
    Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA)univerahealthcare2026-10-15
    Percutaneous Ventricular Assist DeviceUnitedHealthcare2026-10-01
    Cardiovascular Disease Risk AssessmentOscar Health2026-10-01
    Biomarkers for Myocardial Infarction and Chronic Heart FailureOscar Health2026-10-01
    Multiple Procedure Payment Reduction for Diagnostic Cardiovascular ProceduresBlue Cross Blue Shield - Maine2026-10-01
    Left Atrial Appendage Closure Devicesexcellus_health_plan_inc2026-09-17
    Left Atrial Appendage Closure Devicesuniverahealthcare2026-09-17
    Cardiac Omnibus CodesCigna2026-09-15

    Related Codes

    CPT-99424-COMPLEX-CHRONIC-CONDITION-CARE-MANAGEMENT-30MIN

    CPT 99424: Complex Chronic Care Management, First 30 Minutes

    CPT-99426-COMPLEX-CHRONIC-CARE-MANAGEMENT-30-MINUTES

    CPT 99426: Complex Chronic Care Management, Clinical Staff 30 Minutes

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
    Published by

    Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

    Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

    May be used when remote physiologic monitoring data are reviewed as part of the care plan and time is documented