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See a sample rate comparisonCPT 99426 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 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
| 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 GV - Attending physician is not employed or paid under agreement by the patient's Hospice provider |
| Complexity Level | Low |
| Medicare Fee Schedule | $67.80 national non-facility rate (2026) · View Medicare rates for 99426 |
| Medicaid Fee Schedule | $54.25 median of the 8 states in the free preview · View Medicaid rates for 99426 |
National average reimbursement for CPT 99426 by major payers:
$72.59
$81.08
$68.46
$106.96
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CPT 99426
5 of 25 sample ratesHigher to lower in this preview
Maternal Fetal Specialists PC
$200.98Published rateTerry Feng
Emory University
$136.53Published rateFadi Khoury
$100.28Published rateCurless Patterson
$64.76Published rateChristina Penfield
Refuah Health Center Inc
$46.27Published rate
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See a sample payer proposalCPT 99426 vs. Other Preventive Medicine Services Codes
The CPT 99426 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 99426 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 |
|---|---|---|
| 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 |
| 99427-CPT | Low | Prin Care Mgmt Staff 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 Of Clinical Staff Time Directed By A Physician Or Other Qualified Health Care Professional Per Calendar Month List Separately In Addition To Code For Primary Procedure |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99426. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99426 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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