CPT 99426 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Evaluation and Management • Preventive Medicine Services |
| Common Place of Service | • 11 - Office • None • 99 - Other POS |
| Common Modifiers | • None • 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 | Moderate |
National average reimbursement for CPT 99426 by major payers:
$72.59
$81.08
$68.46
$109.49
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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CPT 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 |
|---|---|---|
| 99421 | Low | Online Digital Evaluation And Management Service For An Established Patient For Up To 7 Days Cumulative Time During The 7 Days; 5-10 Minutes |
| 99422 | Low | Online Digital Evaluation And Management Service For An Established Patient For Up To 7 Days Cumulative Time During The 7 Days; 11-20 Minutes |
| 99424 | Low | 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. |
| 99426 | Low | 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 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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Medicare Reimbursement Lookup Tool
Medicare localities are geographic regions used to adjust reimbursement rates based on local costs. Rates vary by locality to reflect differences in wages, rent, and other expenses. Sign up to see commercial rates (United/BCBS/Cigna/Aetna)
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