Talk with us RATES & INSURANCE
Compare published references by county and service. Separate the allowed amount from collections, payer contracts and facility revenue.
CMS finalized new RPM/RTM initiating-visit and valuation rules for January 2027, an established-patient requirement for RTM, and a direct-employee requirement for monitoring clinical staff beginning January 2029. The table below is a 2026 reference; it is not a 2027 quote.
What changed and when →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.
Use the guided facility explorer for state-specific professional references and conditional Medicaid crossover examples. California’s quick table stays below.
RELATED TOOLS
THE WORK-TO-CLAIM GAP
The opportunity is not to bill more indiscriminately. It is to find work that already aligns—or can appropriately align—with a recognized care pathway and make every required step reliable.
The visit is completed, but recurring care needs, consent, time, and a suitable longitudinal program are not evaluated.
Medication review, function, adherence, treatment response, and care-plan work may remain scattered across calls and notes.
Staff make calls, reconcile needs, and coordinate services, but eligibility, consent, a maintained plan, and attributable time may be missing.
Outreach occurs, but discharge notification, contact timing, medication reconciliation, decision-making, or the required visit is unreliable.
A COMPLIANT REVENUE PATHWAY
Select a gate to see the evidence it requires and the risk created when it is skipped.
Diagnosis, risk, clinical need, and a program that is appropriate for the patient.
Starting with a code instead of a medically appropriate patient pathway.
No automatic billing promises. Not every phone call, telehealth visit, device reading, or medication discussion is separately billable. Medical necessity, code requirements, payer policy, provider eligibility, supervision, timing, and non-duplication rules govern each claim.
WHO MAY PAY
| Payer | What it means | What must be verified |
|---|---|---|
| Original Medicare | National program rules with code-level requirements under the Physician Fee Schedule or Part D, depending on the service. | Verify beneficiary eligibility, provider type, service requirements, frequency, exclusions, cost sharing, and local payment. |
| Medicare Advantage | Plans generally cover Medicare benefits but may apply plan-specific authorization, network, documentation, and claim rules. | Verify benefits and operational requirements with the member’s exact plan before enrollment or billing. |
| Medicaid | Coverage and payment vary substantially by state and delivery system. | Confirm the state program, managed-care plan, provider enrollment, eligible codes, and telehealth or monitoring policy. |
| Commercial plans | Coverage is driven by payer policy and the provider contract. | Check benefits, medical policy, authorization, frequency, patient responsibility, and contracted rates. |
MAKE THE PAYER QUESTION SPECIFIC
Before a revenue projection, distinguish Original Medicare from Medicare Advantage, California managed care, FQHC/RHC rules, commercial contracts, and the patient’s actual cost-share path.
CODE-FAMILY ORIENTATION
These representative code families help visitors understand how the programs are structured. They are not a fee schedule, coding recommendation, or confirmation that a service may be billed for a particular patient.
| Program | Representative code family | What it generally organizes |
|---|---|---|
| RPM | 99453, 99445, 99454, 99470, 99457, 99458, 99091 | Setup, two alternative device/data-day bands, two alternative first-time management bands, additional management time, and practitioner analysis. |
| RTM | 98975–98981; 98979, 98984, 98985 added for 2026 | Setup, device-supply, and treatment-management services for qualifying therapeutic data and practitioner types. |
| CCM | 99490, 99439, 99487, 99489, 99491, 99437 | Non-complex, complex, and practitioner-provided chronic-care management families. |
| PCM | 99424–99427 | Monthly disease-specific management for one qualifying high-risk chronic condition. |
| TCM | 99495, 99496 | Thirty-day transition services distinguished by medical-decision-making and required follow-up timing. |
| BHI / CoCM | 99484, 99492–99494, G2214 and applicable add-ons | General behavioral-health integration and psychiatric collaborative-care pathways have different team and time requirements. |
| APCM | G0556–G0558 | Monthly, non-time-based advanced-primary-care levels based on patient complexity. |
| PIN | G0023, G0024, G0140, G0146 | Principal illness navigation and behavioral-health peer-support navigation services. |
| Chronic Pain | G3002, G3003 | Monthly chronic-pain management and treatment bundle plus qualifying additional time. |
| MTM | Part D plan program | MTM eligibility, delivery, documentation, and payment are established through the beneficiary’s Part D plan rather than one universal PFS pathway. |
CPT and HCPCS code sets, descriptors, edits, payer policies, and payment rules change. Verify the current year’s official CMS and payer guidance and consult qualified coding resources before billing.
WHERE PRIMEVITAL ADDS VALUE
Analyze patient mix, current outreach, payer mix, program fit, and operational readiness.
Define enrollment, consent, devices, outreach, escalation, time capture, and documentation standards.
Support eligibility, coding workflow, documentation quality, charge capture, and handoff to billing.
Track claims, payments, denials, AR, and the operational causes that prevent repeatable collection.
This content is general operational information and is not legal, coding, billing, or reimbursement advice. Policies and payment change. Provider organizations should validate current CMS guidance, payer policy, contracts, state law, and professional coding advice before billing.
REVENUE OPPORTUNITY REVIEW
We will review care already being delivered, payer mix, documentation, charge capture, denials, AR, and the operational gaps that may be suppressing collectible revenue.
DESIGN A PRACTICAL STARTING POINT
