Billing code 99425: Principal care managementMedicare rate & RVUs in Ohio
Reports each additional 30 minutes of physician or qualified professional time managing a single high-risk chronic condition during a calendar month.
Medicare pays $59.24 for 99425 in the office in Ohio (Ohio). Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
What 99425 covers
Code 99425 captures each additional 30 minutes a physician or other qualified health care professional spends managing a patient’s single complex, high-risk chronic condition during a calendar month. The condition is expected to last at least three months and places the patient at risk of hospitalization, exacerbation, or functional decline. Work may include carrying out or revising a condition-specific care plan and coordinating with specialists, the patient, or caregivers. Heart failure and COPD are common examples of conditions that may require this focused management.
Report 99425 with 99424, the initial physician or qualified professional principal care management time code, after documenting the additional time and the condition-focused management performed. Keep records of the care plan, coordination, and cumulative monthly time to support the service. CMS classifies 99425 as an add-on code: it must be billed with a primary procedure and is paid within that procedure’s global period.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
99425 in Ohio
| Payment locality | Office | Facility |
|---|---|---|
| Ohio | $59.24 | $43.38 |
How the 99425 rate is calculated
Each of 99425’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 99425
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.00Practice expense 0.77Malpractice 0.07
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 99425
The CMS indicators that decide how 99425 is paid alongside other services.
CMS payment indicators · 99425
Principal care management
| Rule | CMS value | What it means |
|---|---|---|
| Global period | ZZZ | Add-on code: falls within the primary procedure’s global period. |
| Multiple procedures | 0 | No multiple-procedure reduction. |
| Bilateral (modifier 50) | 0 | The 150% bilateral adjustment doesn’t apply. |
| Assistant at surgery (80/81/82/AS) | 0 | Not paid without supporting documentation. |
| Co-surgeons (62) | 0 | Not permitted. |
| Team surgery (66) | 0 | Not permitted. |
| Professional/technical | 0 | Physician service: no professional/technical split. |
99425 compared with similar codes
Compare codes
99425 vs 99424 vs 99427 vs 99437: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 99424Principal care management
- 99424 covers the initial physician or qualified professional principal care management time for the month. Use 99425 only for additional time and report it with 99424.
- 99427Principal care management
- 99427 captures additional principal care management time furnished by clinical staff. 99425 is for additional physician or qualified professional time.
- 99437Chronic care management
- 99437 is additional time for chronic care management; 99425 is additional time focused on managing a single high-risk chronic condition under principal care management.
99425 billing questions
When should 99425 be reported instead of 99424?
99424 reports the initial physician or qualified professional principal care management time for the month. Report 99425 for each additional 30-minute increment after that initial service, with 99424 as the primary code.
Can 99425 be billed by itself?
No. CMS identifies it as an add-on code that must be billed with a primary procedure; for this service, pair it with 99424.
What documentation supports an additional unit?
Document the qualifying high-risk condition, the condition-specific care management performed, and the additional time accumulated during the calendar month. The record should also support the care plan and coordination activities.
Can clinical staff time be counted toward 99425?
99425 represents additional physician or other qualified health care professional time. The clinical-staff principal care management codes are 99426 and 99427.
Is 99425 reported once per month or for each increment?
It is reported for each additional 30-minute increment of qualifying physician or qualified professional time in the calendar month, alongside the initial service reported with 99424.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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