CPT 99496 Fee Schedule
Last Updated: April 2025
Transitional Care Management Services With The Following Required Elements: Communication (Directcontact 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 (Desc Rvsd 1/1/23)
Healthcare providers use this code to document and receive reimbursement for visits that address high-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Evaluation and Management • Transitional Care Management Services |
| Common Place of Service | • 11 - Office • None • 99 - Other Place of Service |
| Common Modifiers | • None • 25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service • 95 - Synchronous telemedicine service via real-time audio and video telecommunications |
| Complexity Level | High |
National average reimbursement for CPT 99496 by major payers:
$291.98
$303.43
$300.75
$419.34
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99496. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99496 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.
CPT 99496 vs. Other Transitional Care Management Services Codes
The CPT 99496 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 99496 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.
| CPT Code | Complexity Level | Description |
|---|---|---|
| 99350 | High | 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.(Desc Rvsd 1/1/23) |
| 99495 | Moderate | Transitional Care Management Services With The Following Required Elements: Communication (Directcontact Telephone Electronic) With The Patient And/Or Caregiver Within 2 Business Days Of Discharge At Least Moderate Level Of Medical Decision Making During The Service Period Face-To-Face Visit Within 14 Calendar Days Of Discharge (Desc Rvsd 1/1/23) |
| 99496 | High | Transitional Care Management Services With The Following Required Elements: Communication (Directcontact 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 (Desc Rvsd 1/1/23) |
| 99497 | Low | Advance Care Planning Including The Explanation And Discussion Of Advacne 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 |
See what providers are getting paid in 2024 for 99496:
CPT 99496 Fee Schedule & Reimbursement Rates
The CPT 99496 fee schedule varies by payer type. Below are Medicare rates for 2024 and average in-network rates by state across major payers:
| Code | Medicare Rate | Avg. Cigna National Rate | More Info |
|---|---|---|---|
| 99350 | $183.75 | ||
| 99495 | $206.72 | $308.30 | |
| 99496 | $279.62 | $419.34 | |
| 99497 | $81.89 | $148.47 | |
| 99498 | $70.90 | $129.92 | |
| 99499 | $188.67 |
Reimbursement rates depend on provider contracts, region, and payer. Always verify rates with your insurance provider or medical billing department.
What is price transparency?
The Price Transparency Rule is a federal law that took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). In short, this regulation mandates that insurance companies make healthcare costs transparent to the public.
Our data comes directly from these insurer-posted MRFs, ensuring compliance with the Price Transparency Rule. While PayerPrice is working toward a future where providers and payers collaborate for 100% upfront price certainty, it's important to acknowledge that data limitations and occasional errors may exist.
Healthcare Price Transparency Rule
cms.govConsumer Guide To Healthcare Prices
aha.orgGlossary of Healthcare Terms
healthcare.govUnlock access to price transparency insights today.
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