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See a sample rate comparisonCPT 99495 Fee Schedule
Last Verified: October 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 | Evaluation and Management Transitional Care Management Services |
| Common Place of Service | 11 - Office 19 - Off Campus Outpatient Hospital |
| Common Modifiers | 25 - Significant, separately identifiable E/M service same day 95 - Telemedicine - audio and video |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $220.11 national non-facility rate (2026) · View Medicare rates for 99495 |
| Medicaid Fee Schedule | $173.40 median of the 8 states in the free preview · View Medicaid rates for 99495 |
National average reimbursement for CPT 99495 by major payers:
$213.19
$222.37
$220.61
$300.65
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CPT 99495
5 of 25 sample ratesHigher to lower in this preview
Qaiser Saeed
Texas Health Physicians Group
$606.57Published rateMir Ali Khan
Christus Trinity Clinic
$247.72Published rateMohammed Khan
Heart Institute Of East Texas, P.A.
$208.80Published rateRaul Martinez
$150.13Published rateAbha Gyani
Hansen Health Solutions PLLC
$94.65Published rate
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See a sample payer proposalCPT 99495 vs. Other Transitional Care Management Services Codes
The CPT 99495 code is part of the Evaluation and Management services used for Transitional Care Management Services. 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 |
|---|---|---|
| 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 |
| 99498-CPT | Low | Advncd Care Plan Addl 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 Each Additional 30 Minutes List Separately In Addition To Code For Primary Procedure |
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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Frequently Asked Questions
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.
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.
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.
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.
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.
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.