CPT 99496 Fee Schedule
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 • 99 - Other POS |
| Common Modifiers | • None • 25 - Significant, separately identifiable E/M service same day • 95 - Telemedicine - audio and video |
| Complexity Level | High |
National average reimbursement for CPT 99496 by major payers:
$291.98
$303.80
$300.75
$419.34
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
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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.
| Code | Complexity | 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 |
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.
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Medicare Reimbursement Lookup Tool
Medicare localities are geographic regions used to adjust reimbursement rates based on local costs. Rates vary by locality to reflect differences in wages, rent, and other expenses. Sign up to see commercial rates (United/BCBS/Cigna/Aetna)
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| Year | Billing Code | Locality | Non-Facility Fee | Facility Fee |
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