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See a sample rate comparisonCPT 99425 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
Prin Care Mgmt Phys Ea Addl, Principal Care Management Services For A Single High Risk Disease With The Following Required Elements One Complex Chronic Condition Expected To Last At Least 3 Months And That Places The Patient At Significant Risk Of Hospitalization Acute Exacerbation Decompensation Functional Decline Or Death The Condition Requires Development Monitoring Or Revision Of Disease Specific Care Plan The Condition Requires Frequent Adjustments In The Medication Regimen And Or The Management Of The Condition Is Unusually Complex Due To Comorbidities Ongoing Communication And Care Coordination Between Relevant Practitioners Furnishing Care Each Additional 30 Minutes Provided Personally By A Physician Or Other Qualified Health Care Professional Per Calendar Month List Separately In Addition To Code For Primary Procedure
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Preventive Medicine Services |
| Common Place of Service | 11 - Office 99 - Other POS |
| Common Modifiers | 25 - Significant, separately identifiable E/M service same day GT - Via interactive audio and video telecommunication systems |
| Complexity Level | Low |
| Medicare Fee Schedule | $61.46 national non-facility rate (2026) · View Medicare rates for 99425 |
| Medicaid Fee Schedule | $50.395 median of the 8 states in the free preview · View Medicaid rates for 99425 |
National average reimbursement for CPT 99425 by major payers:
$72.78
$77.24
$64.33
$102.57
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CPT 99425
5 of 25 sample ratesHigher to lower in this preview
Devina Savant
Mass General Brigham Incorporated
$179.83Published rateMichael Kwan
$110.47Published rateSurya Lanka
Surya P. Lanka, M.D.
$82.08Published rateTexoma Neurology Associates, PA
Texoma Neurology Associates, P.A.
$62.79Published rateThomas Porter
Porter Healthcare Services Inc
$43.88Published rate
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See a sample payer proposalCPT 99425 vs. Other Preventive Medicine Services Codes
The CPT 99425 code is part of the Evaluation and Management services used for Preventive Medicine Services. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 99425 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 99421-CPT | Low | Online Digital Evaluation And, Online Digital Evaluation And Management Service For An Established Patient For Up To 7 Days Cumulative Time During The 7 Days 5-10 Minutes |
| 99424-CPT | Low | Prin Care Mgmt Phys 1st 30, Principal Care Management Services For A Single High Risk Disease With The Following Required Elements One Complex Chronic Condition Expected To Last At Least 3 Months And That Places The Patient At Significant Risk Of Hospitalization Acute Exacerbation Decompensation Functional Decline Or Death The Condition Requires Development Monitoring Or Revision Of Disease Specific Care Plan The Condition Requires Frequent Adjustments In The Medication Regimen And Or The Management Of The Condition Is Unusually Complex Due To Comorbidities Ongoing Communication And Care Coordination Between Relevant Practitioners Furnishing Care First 30 Minutes Provided Personally By A Physician Or Other Qualified Health Care Professional Per Calendar Month |
| 99425-CPT | Low | Prin Care Mgmt Phys Ea Addl, Principal Care Management Services For A Single High Risk Disease With The Following Required Elements One Complex Chronic Condition Expected To Last At Least 3 Months And That Places The Patient At Significant Risk Of Hospitalization Acute Exacerbation Decompensation Functional Decline Or Death The Condition Requires Development Monitoring Or Revision Of Disease Specific Care Plan The Condition Requires Frequent Adjustments In The Medication Regimen And Or The Management Of The Condition Is Unusually Complex Due To Comorbidities Ongoing Communication And Care Coordination Between Relevant Practitioners Furnishing Care Each Additional 30 Minutes Provided Personally By A Physician Or Other Qualified Health Care Professional Per Calendar Month List Separately In Addition To Code For Primary Procedure |
| 99426-CPT | Low | Prin Care Mgmt Staff 1st 30, Principal Care Management Services For A Single High Risk Disease With The Following Required Elements One Complex Chronic Condition Expected To Last At Least 3 Months And That Places The Patient At Significant Risk Of Hospitalization Acute Exacerbation Decompensation Functional Decline Or Death The Condition Requires Development Monitoring Or Revision Of Disease Specific Care Plan The Condition Requires Frequent Adjustments In The Medication Regimen And Or The Management Of The Condition Is Unusually Complex Due To Comorbidities Ongoing Communication And Care Coordination Between Relevant Practitioners Furnishing Care First 30 Minutes Of Clinical Staff Time Directed By Physician Or Other Qualified Health Care Professional Per Calendar Month |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99425. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99425 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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