CPT 99425
Global ZZZ ActivePrin care mgmt phys ea addl
CPT 99425 Billing & Documentation Guide
CPT code 99425 (Prin care mgmt phys ea addl) is classified under E/M with a global period indicator of ZZZ. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 1, a non-facility practice expense RVU of 0.77, and a malpractice RVU of 0.07, a total non-facility RVU of 1.84 and facility RVU of 1.32. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $62.93, though rates vary from $56.7 to $78.78 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99425, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 99425 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
Add-on code (global concept does not apply)
MUE Limit (Medically Unlikely Edits)
Submitting more than 2 units of 99425 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 99425
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 1 | 1 |
| Practice Expense RVU | 0.77 | 0.25 |
| Malpractice RVU | 0.07 | 0.07 |
| Total RVU | 1.84 | 1.32 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99425
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $66.3 | $45.74 | $63.41 - $75.41 | 29 |
| Florida | $63.76 | $46.33 | $61.5 - $66.09 | 3 |
| Georgia | $60.79 | $44.22 | $59.13 - $62.44 | 2 |
| Illinois | $62.84 | $46.05 | $60.54 - $64.85 | 4 |
| Michigan | $60.84 | $44.53 | $59.52 - $62.16 | 2 |
| North Carolina | $58.89 | $42.69 | $58.89 - $58.89 | 1 |
| New York | $66.85 | $47.48 | $59.48 - $70.46 | 5 |
| Ohio | $59.24 | $43.38 | $59.24 - $59.24 | 1 |
| Pennsylvania | $61.39 | $44.38 | $59.22 - $63.56 | 2 |
| Texas | $61.08 | $43.98 | $58.98 - $62.75 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 99425
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99425 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 36591 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 36592 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90960 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90961 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90962 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90963 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90964 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90965 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90966 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
| 90967 | Column 1 (primary), can be billed with modifier | No | CPT Manual or CMS manual coding instruction |
Frequently Asked Questions, CPT 99425
What does CPT code 99425 mean? +
CPT code 99425 represents: Prin care mgmt phys ea addl. It's in the E/M category with a global period of ZZZ.
What is the Medicare reimbursement for CPT 99425? +
The 2026 Medicare national average non-facility payment for CPT 99425 is $62.93. Rates range from $56.7 to $78.78 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99425? +
E/M codes commonly use modifier 25 (significant separately identifiable E/M on same day as a procedure), 57 (decision for major surgery), 24 (unrelated E/M during global period), 95 (synchronous audio+video telehealth), 93 (audio-only telehealth), and AI (principal physician of record on admission). Surgical modifiers like 50, 51, 59 do not apply to E/M.
What bundling edits apply to CPT 99425? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on June 1, 2026.
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