Billing code 99426: Principal care managementMedicare rate & RVUs in Oregon
Reports the first 30 minutes of clinical-staff work in a calendar month managing one complex chronic condition under physician or qualified professional direction.
Medicare pays $66.98–$71.30 for 99426 in the office in Oregon, from Rest Of Oregon to Portland. 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 99426 covers
99426 reports clinical-staff work in principal care management for a patient with one complex chronic condition expected to last at least three months and carrying significant risk, such as complex heart failure requiring ongoing medication and specialist coordination. Nursing staff perform the care-management work under a physician’s or other qualified health care professional’s direction. Activities may include implementing or revising a disease-specific care plan and coordinating with the patient, caregivers, and treating clinicians in an office or other care setting.
Report 99426 for the first 30 minutes of qualifying staff time in a calendar month; use 99427 for each additional 30 minutes. Physician or qualified professional time for this service is represented by 99424 and 99425, rather than staff time under 99426. Documentation should identify the condition and care plan, describe the work performed and staff direction, and record the qualifying minutes and month. The PFS assigns work, practice-expense, and malpractice RVUs, with separate office and facility practice-expense values.
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.
Where 99426 pays more and less in Oregon
| Payment locality | Office | Facility |
|---|---|---|
| Portland | $71.30 | $44.95 |
| Rest Of Oregon | $66.98 | $43.36 |
How the 99426 rate is calculated
Each of 99426’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 · 99426
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 1.00Practice expense 0.96Malpractice 0.07
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
Payment rules and modifiers for 99426
99426 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.
Place of service · 99426
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
Non-facility (office) rate · national
$67.80
The facility rate would be $44.09 (+$23.71). In a facility, the facility bills its own costs separately.
99426 compared with similar codes
Compare codes
99426 vs 99424 vs 99425 vs 99427 vs 99439: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 99424Principal care management
- Choose 99424 for the initial 30 minutes of physician or qualified professional PCM time; choose 99426 for the initial 30 minutes of qualifying clinical-staff time.
- 99425Principal care management
- 99425 reports additional PCM time furnished by the physician or qualified professional. 99426 is the initial staff-time code.
- 99427Principal care management
- 99427 reports each additional 30 minutes of staff PCM time after the initial increment represented by 99426.
- 99439Chronic care management
- 99439 is an add-on for clinical-staff chronic care management time; 99426 reports the initial staff-time increment for principal care management focused on one complex chronic condition.
99426 billing questions
When should staff report 99426 instead of 99424?
Use 99426 for qualifying clinical-staff time under physician or qualified professional direction. Code 99424 represents the initial 30 minutes of the physician’s or qualified professional’s own PCM time.
What code reports PCM staff time beyond the first 30 minutes?
99427 is the add-on code for each additional 30 minutes of qualifying clinical-staff time in the calendar month.
Can 99426 be reported with fewer than 30 minutes?
99426 represents the initial 30-minute increment. The record should support at least 30 minutes of qualifying staff work during that calendar month.
What should the record show?
Document the complex chronic condition, the disease-specific care plan, the staff’s care-management activities and direction, and the total qualifying staff time for the month.
Can the same staff minutes support another time-based service?
Do not count the same minutes twice. Track time attributed to PCM separately from time attributed to other services.
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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