How much does Medicare pay for CPT 99425?

Medicare allowed an average of $58.97 per service and paid $46.11 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $120.92, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

Does 99425 pay differently in an office than a hospital?

Yes. The allowed amount averaged $58.99 in an office setting and $51.67 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 99425 most?

Family Practice, with 3,179 services from 4 clinicians. Next are Nurse Practitioner, Physical Medicine and Rehabilitation, Internal Medicine.

CPT 99425

Principal care management services for a single high-risk disease, each additional 30 minutes provided personally by qualified health care professional, per calendar month

$58.97Medicare-allowed amount per service, averaged across 11,788 services

Providers submitted

$120.92

Asking price, not received

Medicare allowed

$58.97

The fee schedule figure

Medicare paid

$46.11

Balance is patient coinsurance

Providers submitted an average of $120.92 for this code and Medicare allowed $58.97 — 2.1× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $46.11 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $58.99
Hospital / facility: $51.67

The office rate is higher because the practice supplies the room, staff and equipment out of that payment. In a hospital the facility bills those separately, so the clinician's share is smaller — the total cost to Medicare is usually higher, not lower. 11,751 services were billed in an office setting and 37 in a facility.

Services: 11,788
Beneficiaries: 3,788
Providers billing it: 79
Total allowed: $695,138

What Medicare pays for CPT 99425

Across 11,788 services billed by 79 providers to 3,788 beneficiaries, Medicare allowed an average of $58.97 per service. That is 3.1 services per beneficiary, so this is a code patients typically receive more than once. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 99425

Specialty	Services	Beneficiaries	Avg allowed	Providers
Family Practice	3,179	487	$62.86	4
Nurse Practitioner	1,930	823	$49.06	18
Physical Medicine and Rehabilitation	1,788	365	$62.31	4
Internal Medicine	1,374	472	$63.93	6
Cardiology	995	276	$57.16	11
Endocrinology	543	196	$58.05	6
Pain Management	488	103	$57.00	1
Physician Assistant	409	354	$51.36	9
Anesthesiology	177	87	$65.45	1
Orthopedic Surgery	172	163	$55.26	6
Otolaryngology	158	101	$59.53	1
Nephrology	139	68	$57.57	2
Sports Medicine	127	118	$59.36	2
Pulmonary Disease	92	36	$58.82	1
Gastroenterology	75	46	$57.53	1

99425 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
New Jersey	2,460	$63.51	$46.44	2
District of Columbia	2,106	$65.58	$44.03	2
Texas	1,916	$51.80	$42.31	11
Illinois	1,559	$59.42	$46.77	3
North Carolina	1,217	$56.26	$44.93	15
Arizona	596	$57.19	$47.19	5
New York	476	$54.00	$41.49	13
California	443	$62.00	$46.83	6
Florida	344	$54.15	$41.72	6
South Carolina	93	$47.90	$39.85	1
Tennessee	74	$46.88	$37.81	1
Georgia	69	$51.27	$39.93	1
Missouri	67	$48.89	$37.99	1
Nevada	61	$49.81	$39.93	2
Pennsylvania	51	$51.07	$39.93	1
Michigan	46	$60.22	$43.30	1
South Dakota	35	$48.70	$39.76	1
Virginia	31	$58.01	$44.51	1
Washington	30	$51.05	$39.93	1
Massachusetts	29	$57.56	$39.92	1
Oklahoma	26	$55.36	$46.50	1
Colorado	24	$59.97	$44.92	1
Rhode Island	20	$49.83	$39.93	1
North Dakota	15	$52.29	$39.84	1

Related codes

99490Chronic care management services$59.70
99439Chronic care management services for two or more chronic conditions$46.13
99497Advance care planning$73.95
99457Management using the results of remote vital sign monitoring per calen$48.61
99458Management using the results of remote vital sign monitoring per calen$39.11
99454Remote monitoring of physiologic parameters$47.97
99489Complex chronic care management services for two or more chronic condi$67.00
99442Telephone medical discussion$83.84
99443Telephone medical discussion$120.39
99487Complex chronic care management services for two or more chronic condi$124.70
99496Transitional care management services for problem of high complexity$252.87
99426Principal care management services for a single high-risk disease$60.08

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.