Summary & Overview

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

Headline: CPT code 99426 defines the first 30 minutes per month of clinical staff time for management of patients with complex chronic conditions. Lead: CPT code 99426 covers clinical staff–delivered care plan and management services under physician or qualified professional direction for patients with complex chronic conditions expected to last three months or more and who are at significant risk for hospitalization, decompensation, or functional decline.

What this code represents and why it matters: CPT code 99426 formalizes reimbursement for team-based care activities performed by clinical staff, reflecting the increasing emphasis on care coordination for high-risk chronic patients. National attention on value-based care and reducing avoidable hospitalizations makes this code relevant to practices aiming to document and bill for structured monthly care management time.

Key payers covered: Analysis includes major national payers: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

What readers will learn: The publication outlines the clinical context and appropriate use of CPT code 99426, common modifiers and billing considerations, payer coverage patterns, and operational implications for ambulatory practices. It also presents benchmarks where available and notes policy updates affecting chronic care management billing. Data not available in the input is identified where applicable.

AetnaBlue Cross Blue ShieldCigna HealthUnitedHealthcareMedicareCPT 99426chronic care managementcare coordinationclinical staff servicesoutpatient carevalue-based carebilling and codingcare plan services

Billing Code Overview

CPT code 99426 describes clinical staff time, under the direction of a physician or other qualified healthcare professional, devoted to management and care plan services for a patient with a complex chronic condition expected to last at least three months and that places the patient at significant risk of hospitalization, acute exacerbation, decompensation, functional decline, or death. Use of 99426 applies to the first 30 minutes of clinical staff time per calendar month.

Service type: Clinical staff–provided chronic care management and care plan services directed by a physician or other qualified healthcare professional.
Typical site of service: Primarily outpatient and ambulatory settings where care management is coordinated (for example, primary care clinics, specialty outpatient practices, and community-based care management programs).

Clinical & Coding Specifications

Clinical Context

A 72-year-old patient with advanced chronic heart failure (New York Heart Association class III), chronic kidney disease stage 3, and type 2 diabetes is enrolled in a complex chronic condition management program. The patient is at significant risk of hospitalization from volume overload, acute kidney injury, or glycemic decompensation. A primary care physician directs clinical staff (RN care manager and licensed practical nurse) to perform monthly care plan management activities. During the first calendar month of enrollment, the RN spends 30 minutes of directed time coordinating the care plan: reviewing hospital discharge summaries, reconciling medications, documenting symptom trends, arranging home health visits, educating the patient/caregiver on self-monitoring, and scheduling telehealth follow-up with the physician.

The clinical workflow begins with the physician documenting the diagnosis and directing clinical staff to provide management under a defined care plan. Clinical staff perform tasks such as chart review, patient outreach by telephone or secure messaging, medication reconciliation, assessment of adherence and barriers, care coordination with specialists and community services, and documentation of time and activities in the medical record. The staff escalate any identified clinical changes to the supervising physician or other qualified healthcare professional. Billing for the first 30 minutes of clinical staff time for the month is submitted using 99426 under the supervising provider’s NPI and appropriate facility/site of service designation (commonly outpatient clinic, home health coordination, or telehealth-enabled care management).

Coding Specifications

Modifier	Description	When to Use

Taxonomy Code	Specialty	Notes
`208000000X`	Family Medicine	Common supervising specialty for complex chronic care management performed in outpatient primary care.
`207Q00000X`	Internal Medicine	Frequently directs CCM programs for adult patients with multiple chronic conditions.
`207R00000X`	Emergency Medicine	May direct transition-of-care CCM activities after ED visit for high-risk patients.
`163W00000X`	Nurse Practitioner	Clinically directs or supervises clinical staff performing CCM activities under provider protocols.
`363A00000X`	Registered Nurse	Clinical staff role executing the `99426` defined services; taxonomy used when billing requires RN credentials.

ICD-10 Code	Description	Clinical Relevance
`I50.33`	Acute on chronic systolic (congestive) heart failure	Patients with chronic heart failure are at high risk of decompensation and hospitalization; CCM services support monitoring and care coordination.
`N18.3`	Chronic kidney disease, stage 3 (moderate)	CKD increases complexity of medication management and risk of acute kidney injury; CCM addresses care coordination and monitoring.
`E11.9`	Type 2 diabetes mellitus without complications	Common comorbidity that increases management complexity and risk of acute events requiring coordination and monitoring.
`J44.9`	Chronic obstructive pulmonary disease, unspecified	COPD patients are at risk for exacerbations and hospitalization; CCM supports prevention and early intervention.
`I25.10`	Atherosclerotic heart disease of native coronary artery without angina pectoris	Chronic cardiovascular disease contributing to overall complexity and need for care coordination.
`M81.0`	Age-related osteoporosis without current pathological fracture	Contributes to functional decline risk and necessitates multidisciplinary management often captured in CCM plans.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99426`	Clinical staff time, directed by a physician or other qualified health care professional, for patients with a complex chronic condition; first 30 minutes of clinical staff time per calendar month	Primary code described; used for first 30 minutes of clinical staff CCM time per month.
`99427`	Clinical staff time, directed by a physician or other qualified health care professional, for patients with a complex chronic condition; each additional 30 minutes per calendar month	Used when clinical staff time exceeds the initial 30 minutes in the same calendar month to capture additional directed CCM time.
`99490`	Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, for patients with two or more chronic conditions	Alternative monthly chronic care service for patients who meet non-complex CCM criteria; may be used in different care pathways.
`99487`	Complex chronic care management services, with moderate or high complexity medical decision making, 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month	Used for higher complexity CCM when billing directly for time-based complex CCM by the supervising provider.
`G2064`	Chronic care management with psychiatric collaborative care management, per month (note: HCPCS/G-code usage varies)	May be used in workflows integrating behavioral health collaborative care with medical CCM where payers recognize the code.

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