CPT 99495 is a medical code used by healthcare providers to document and receive reimbursement for transitional care management services involving moderate-level medical decision-making. Key requirements include communication with the patient or caregiver within 2 business days of discharge and a face-to-face visit within 14 calendar days of discharge.

How does CPT 99495 compare to other Transitional Care Management Services codes?

CPT 99495 represents a moderate-complexity transitional care management service, requiring more provider time and moderate medical decision-making than lower-level codes. It typically involves multiple diagnoses, medication management, or test interpretation. Other codes, like 99496, are for high-complexity TCM services, while codes like 99350 are for high-complexity home/residence visits.

What factors affect fee schedules?

Fee schedules are influenced by several factors: government-set Medicare & Medicaid rates, negotiated private insurance rates between providers and insurance companies, geographic location (e.g., higher costs in urban areas), and provider type (e.g., hospital vs. private practice rates).

How can I find out the cost of a specific medical procedure or service before I receive it?

To find out the cost of a specific medical procedure or service beforehand, you should first contact your healthcare provider's billing department to request a good faith estimate. Also, review your insurance policy or contact your insurer directly to understand your benefits, deductibles, co-pays, and out-of-pocket maximums for the specific service. For a broader search and comparison of fee schedules based on CPT codes and specific locations, you can utilize tools like Payerprice. Payerprice offers a fee schedule lookup tool that allows users to search with CPT codes and specific locations to help estimate costs.

What is a CPT code and why is it important for understanding healthcare costs?

CPT stands for Current Procedural Terminology. CPT codes are a set of medical codes used by healthcare professionals to describe the services and procedures they provide to patients. Each service, such as a doctor's visit, surgery, or laboratory test, has a unique five-digit CPT code. These codes are crucial for understanding healthcare costs because they standardize the reporting of medical services, making it possible for insurers to process claims and for patients to compare prices for specific procedures across different providers.

What factors cause the price of a medical procedure to vary between different hospitals or providers?

Several factors contribute to the variation in prices for medical procedures between different hospitals or providers. These include the provider's negotiated rates with insurance companies, the complexity and overhead costs associated with the facility (e.g., academic medical centers versus standalone clinics), geographic location, technology used, differing supply chain costs, and the specific services bundled into a procedure. The presence of specialized equipment, staffing levels, and whether the provider is in-network or out-of-network for a patient's insurance plan also play significant roles.

How can I understand my medical bill and the charges listed on it?

Understanding your medical bill involves several steps. First, compare the services listed on the bill with the services you actually received. Look for CPT codes, which specify the procedures performed. Check for line items that may represent administrative fees, facility fees, or supplies in addition to the main procedure. Your Explanation of Benefits (EOB) from your insurance company will detail what your insurer paid and what you owe. If anything is unclear, don't hesitate to contact the provider's billing department or your insurance company directly for clarification.

Where can I find information about standard healthcare prices or fee schedules?

Information about healthcare prices and fee schedules can be challenging to navigate due to varying negotiated rates. Many providers are now required to offer "good faith estimates" for scheduled services. Your insurance company may also provide tools to estimate costs for in-network providers. For a comprehensive and specific search based on CPT codes and particular locations, Payerprice offers a fee schedule lookup tool. This platform allows users to access fee schedule data to gain insights into potential costs for various medical services in their area.

What is the difference between a negotiated rate and a charge master price?

A charge master price, also known as a list price or sticker price, is the full price a hospital sets for a medical service or procedure before any discounts or negotiations. It's often the highest possible price. A negotiated rate, on the other hand, is the discounted price that an insurance company has agreed upon with a healthcare provider for a specific service. Patients with insurance typically pay based on these negotiated rates, not the higher charge master prices, after their deductibles and co-insurance are applied. Uninsured patients may sometimes be billed the charge master price, though they can often negotiate a lower cash price.

CPT 99495 Fee Schedule

Last Verified: July 2026

Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.

Care Management, Assessment Of And Care Planning For A Patient With Cognitive Impairment Requiring An Independent Historian In The Office Or Other Outpatient Home Or Domiciliary Or Rest Home With All Of The Following Required Elements: Cognition-Focused Evaluation Including A Pertinent History And Examination Medical Decision Making Of Moderate Or High Complexity Functional Assessment (Eg Basic And Instrumental Activities Of Daily Living) Including Decision-Making Capacity Use Of Standardized

Key Fact	Detail
Service Type	Transitional Care Management Services Evaluation and Management
Common Place of Service	11 - Office 19 - Off Campus Outpatient Hospital
Common Modifiers	None 25 - Significant, separately identifiable E/M service same day 95 - Telemedicine - audio and video
Complexity Level	Moderate
Medicare Fee Schedule	View Medicare rates for 99495

National average reimbursement for CPT 99495 by major payers:

$213.19

$222.37

$220.61

$300.65

Preview provider-level rates for...

For billing codeCPT 99495

Payer	Code	Rate	NPI	Tax ID	State	Specialty
United	99495	$190.22	1457885238 - LOREN ALBRITTON	752966610 - (TX) PHYSICIAN ASSOCIATES OF SOUTHWEST DALLAS	TX	Internal Medicine Physician (207R00000X)
United	99495	$106.75	1255473195 - MANUEL TELLEZ	453762061 - (TX) MANUEL TELLEZ DO PA	TX	Internal Medicine Physician (207R00000X)
United	99495	$206.72	1902008824 - MUNAIMAA REHMAAN	824236908 - (TX) CARE WELL TX PLLC	TX	Internal Medicine Physician (207R00000X)
United	99495	$94.65	1114960465 - ABHA GYANI	822151891 - (TX) HANSEN HEALTH SOLUTIONS PLLC	TX	Internal Medicine Physician (207R00000X)
United	99495	$606.57	1194883207 - QAISER SAEED	752613493 - TEXAS HEALTH PHYSICIANS GROUP	TX	Internal Medicine Physician (207R00000X)
United	99495	$239.94	1699750687 - MAUREEN FRANCIS	752668018	TX	Internal Medicine Physician (207R00000X)
United	99495	$246.22	1306232616 - WEI TANG	752536818 - HEALTHTEXAS PROVIDER NETWORK	TX	Internal Medicine Physician (207R00000X)
United	99495	$145.60	1740585611 - SHERYL WISER	770000464 - (CA) RADHEY S. BANSAL, M.D., INC.	TX	Internal Medicine Physician (207R00000X)
United	99495	$301.48	1588005276 - RIZWAN ALI	550526150 - CHARLESTON AREA MEDICAL CENTER INC	TX	Internal Medicine Physician (207R00000X)
United	99495	$106.75	1043296502 - LIANXI LIAO	751362682 - (TX) FORT WORTH HEART, P.A.	TX	Cardiovascular Disease Physician (207RC0000X)
United	99495	$192.75	1811037286 - PAULGUN SULUR	844955593 - (TX) AP US 14 PA	TX	Internal Medicine Physician (207R00000X)
United	99495	$206.72	1134295843 - NIAZ FARHAT	822122432	TX	Internal Medicine Physician (207R00000X)
United	99495	$444.19	1962956896 - NADEEN AUDISHO	910565889 - PEACEHEALTH ST JOSEPH MEDICAL CENTER	TX	Internal Medicine Physician (207R00000X)
United	99495	$150.13	1285641704 - RAUL MARTINEZ	742080607	TX	Cardiovascular Disease Physician (207RC0000X)
United	99495	$463.92	1356456420 - MAGDA HENNES	756002868	TX	Internal Medicine Physician (207R00000X)
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist
United	99202	$100.00	1234567890	1234567890	CA	Cardiologist

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CPT 99495 vs. Other Evaluation and Management Codes

The CPT 99495 code is part of the Transitional Care Management Services services used for Evaluation and Management. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.

The CPT 99495 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.

Code	Complexity	Description
99350-CPT	High	Home Res Vst Est High Mdm 60, Home Or Residence Visit For The Evaluation And Management Of An Established Patient Which Requires A Medically Appropriate History And Or Examination And High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 60 Minutes Must Be Met Or Exceeded
99495-CPT	Moderate	Care Management, Assessment Of And Care Planning For A Patient With Cognitive Impairment Requiring An Independent Historian In The Office Or Other Outpatient Home Or Domiciliary Or Rest Home With All Of The Following Required Elements: Cognition-Focused Evaluation Including A Pertinent History And Examination Medical Decision Making Of Moderate Or High Complexity Functional Assessment (Eg Basic And Instrumental Activities Of Daily Living) Including Decision-Making Capacity Use Of Standardized
99496-CPT	High	Transj Care Mgmt High F2f 7d, Transitional Care Management Services With The Following Required Elements Communication Direct Contact Telephone Electronic With The Patient And Or Caregiver Within 2 Business Days Of Discharge High Level Of Medical Decision Making During The Service Period Face To Face Visit Within 7 Calendar Days Of Discharge
99497-CPT	Low	Advncd Care Plan 30 Min, Advance Care Planning Including The Explanation And Discussion Of Advance Directives Such As Standard Forms With Completion Of Such Forms When Performed By The Physician Or Other Qualified Health Care Professional First 30 Minutes Face To Face With The Patient Family Member S And Or Surrogate

What is a fee schedule?

A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99495. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.

Understanding the 99495 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.

Factors that affect fee schedules

Medicare & Medicaid Rates

Government-set reimbursement amounts

Private Insurance Rates

Negotiated rates between providers and insurance companies

Geographic Location

Costs may be higher in urban areas.

Provider Type

Hospital providers may have different rates than private practice.

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