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Explore coordinated resident care, professional billing support and staffing without confusing facility payments with practitioner reimbursement.
Explore chronic-condition coordination (CCM), behavioral-health integration (BHI) or condition-specific management with the treating practitioner.
Confirm resident status, staff arrangements, existing services and code-specific requirements. Professional reimbursement is not automatically facility income.
Start with the existing SNF care plan and professional services—not an assumed monthly care-program bundle.
Check the exact code and covered stay dates before forecasting. A facility-rate reference is not permission to bill during the stay.
Assess transitional care management (TCM), then ongoing care coordination or clinically appropriate monitoring.
Identify the receiving practitioner, discharge date, timely contact and follow-up visit. Keep overlapping services and time distinct.
Scenarios to evaluate—not approvals to bill or revenue guarantees.
Professional Medicare allowed amounts are not revenue automatically payable to the nursing home. Validate billability before comparing facility/non-facility rates or Medicaid crossover. Any payment to the facility under a services arrangement needs separate legal review.
Check enrollment, the exact service, stay dates, place of service and existing services. A Part A stay and care after discharge are different situations.
MEDICARE RATE REFERENCES · OCTOBER–DECEMBER 2026
Choose from all 58 California counties and nine program families. The lookup lists 41 active, nationally priced PFS codes, including alternatives and add-ons. It is a code-family reference, not a suggested claim or a complete Medicare code catalog.
How to use: choose county, program and rate setting. Amounts update automatically below; no submit button is needed. 2027 final-rule changes are explained separately; these amounts apply to October–December 2026.
6 codes shown. Base, alternative and add-on rows serve different purposes. Add-ons require their applicable primary service; alternatives are not a list to stack. See each program guide before using a rate.
Office / non-facility: the practitioner’s fee generally includes office-type overhead, such as staff, supplies and equipment.
Hospital / facility: the practitioner’s professional fee generally reflects that an institution bears some overhead. This is not the hospital’s or nursing home’s own payment.
The applicable rate depends on Medicare’s place-of-service rules and the particular service—not simply whether your organization calls itself a facility. Nursing-home residents can have different claim settings; do not select “facility” solely because the patient lives in a nursing home. Confirm the actual setting with your biller or Medicare contractor. Selecting a rate does not establish coverage.
CMS explanation of professional fees and practice expense →CMS locality: SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) · MAC 01112 · locality 05
A building name does not determine the claim’s place of service. A facility rate does not establish that a code is billable during an inpatient or Part A SNF stay.
| Code, role and plain-English service | Medicare allowed amount | Illustrative Medicare portion | Standard 20% cost share |
|---|---|---|---|
| CCM · 99490Base Clinical-staff CCM, first 20 minutes | $80.42 | $63.0580%, then 2% sequestration | $16.08Not automatically collectible |
| CCM · 99439Add-on Clinical-staff CCM, each additional 20 minutes | $62.10 | $48.6980%, then 2% sequestration | $12.42Not automatically collectible |
| CCM · 99487Alternative Complex CCM, first 60 minutes and required decision-making | $180.13 | $141.2280%, then 2% sequestration | $36.03Not automatically collectible |
| CCM · 99489Add-on Complex CCM, each additional 30 minutes | $97.38 | $76.3580%, then 2% sequestration | $19.48Not automatically collectible |
| CCM · 99491Alternative Practitioner-personal CCM, first 30 minutes | $107.00 | $83.8980%, then 2% sequestration | $21.40Not automatically collectible |
| CCM · 99437Add-on Practitioner-personal CCM, each additional 30 minutes | $76.19 | $59.7380%, then 2% sequestration | $15.24Not automatically collectible |
The allowed amount is a fee-schedule reference, not guaranteed collections. The Medicare portion assumes the deductible is met, assigned claims and no other adjustments. For a $100 allowed amount, the standard split is $80 Medicare and $20 cost sharing; 2% sequestration reduces Medicare’s $80 to $78.40.
Secondary insurance, Medicaid crossover, deductible status and claim-level adjustments change actual collections. QMB patients cannot be billed Medicare cost sharing even when Medicaid pays nothing. Medicare Advantage and commercial rates depend on the actual plan and contract. The higher QP conversion factor is not modelled here.
Patient cost-share guide →Verified against CMS October RVUs and GPCIs (RVU26D), October payment revisions, and the annual California carrier file: 2378 locality/code/setting comparisons. Effective 2026-10-01 through 2026-12-31. This excludes contractor-priced RTM code 98978 and plan-specific Part D MTM payments, which have no universal PFS amount. Descriptions are plain-language summaries, not full coding instructions. CMS source release. Requirements and sources.
This public lookup covers California only. Do not apply these amounts to Florida or another state. A rate reference is not a facility revenue estimate.
Define outreach, documentation, staffing and billing handoffs around your existing care. Clinical decisions remain with the responsible professionals.
Service hours, review cadence, urgent contacts and after-hours responsibilities are agreed before enrollment. PrimeVital does not promise continuous device surveillance or a 24/7 nurse line on this website. Emergency symptoms require emergency services, not waiting for routine monitoring review.
No upfront pilot fee; service fees are paid from collections under the written agreement. Confirm fees, timing and insufficient-collection terms before launch.
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