How much does Medicare pay for CPT 99495?

Medicare allowed an average of $182.24 per service and paid $140.80 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $402.84, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 99495?

Transitional care management services for problem of at least moderate complexity. It was billed 414,897 times to 373,547 Medicare beneficiaries by 18,207 providers in 2024.

Does 99495 pay differently in an office than a hospital?

Yes. The allowed amount averaged $184.53 in an office setting and $125.72 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 99495 most?

Family Practice, with 152,018 services from 6,975 clinicians. Next are Internal Medicine, Nurse Practitioner, Physician Assistant.

CPT 99495

Transitional care management services for problem of at least moderate complexity

$182.24Medicare-allowed amount per service, averaged across 414,897 services

Providers submitted

$402.84

Asking price, not received

Medicare allowed

$182.24

The fee schedule figure

Medicare paid

$140.80

Balance is patient coinsurance

Providers submitted an average of $402.84 for this code and Medicare allowed $182.24 — 2.2× 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 $140.80 (77%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $184.53
Hospital / facility: $125.72

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. 398,737 services were billed in an office setting and 16,160 in a facility.

Services: 414,897
Beneficiaries: 373,547
Providers billing it: 18,207
Total allowed: $75,610,829

What Medicare pays for CPT 99495

Across 414,897 services billed by 18,207 providers to 373,547 beneficiaries, Medicare allowed an average of $182.24 per service. 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 99495

Specialty	Services	Beneficiaries	Avg allowed	Providers
Family Practice	152,018	135,630	$184.87	6,975
Internal Medicine	151,824	135,700	$189.87	6,175
Nurse Practitioner	64,858	59,602	$160.23	2,941
Physician Assistant	21,263	19,629	$157.81	1,017
Cardiology	5,921	5,587	$204.20	263
Geriatric Medicine	3,270	2,943	$186.71	122
Nephrology	3,034	2,755	$190.07	147
General Practice	2,074	1,805	$199.92	80
Infectious Disease	1,615	1,440	$204.42	59
Hospitalist	1,512	1,404	$183.95	74
Emergency Medicine	1,208	1,124	$201.58	37
Pulmonary Disease	1,117	1,055	$207.10	55
Interventional Cardiology	1,026	997	$205.50	57
Hematology-Oncology	976	907	$209.90	57
Physical Medicine and Rehabilitation	413	402	$178.20	10

99495 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
Florida	49,281	$189.15	$152.21	1,777
Pennsylvania	35,302	$179.63	$152.21	1,580
California	23,127	$205.03	$151.32	942
Illinois	19,080	$193.68	$151.10	830
New York	18,331	$201.29	$148.44	799
Texas	17,455	$186.08	$149.23	766
Virginia	15,209	$183.15	$144.72	604
Massachusetts	15,015	$194.28	$146.74	725
New Jersey	14,542	$197.67	$155.71	660
Ohio	13,975	$147.99	$142.18	703
Maryland	12,301	$202.86	$154.01	547
North Carolina	11,215	$181.06	$149.35	502
South Carolina	10,712	$182.66	$151.17	477
Georgia	9,913	$186.10	$153.81	434
Kentucky	9,559	$164.53	$150.18	409
Tennessee	8,989	$179.39	$152.20	415
Indiana	8,376	$182.99	$150.86	393
Michigan	8,076	$166.77	$147.29	413
Arizona	7,823	$191.67	$151.97	342
Minnesota	6,732	$186.89	$147.70	345
Arkansas	6,513	$156.91	$147.96	241
Washington	6,502	$189.93	$144.68	319
Kansas	6,475	$166.74	$148.33	264
Wisconsin	6,437	$172.21	$141.16	321
Iowa	6,312	$173.16	$143.43	283
Missouri	5,825	$155.88	$145.09	272
Mississippi	5,746	$170.54	$143.42	231
Alabama	5,380	$183.04	$155.27	247
Oklahoma	5,169	$150.20	$152.77	212
Delaware	4,922	$169.57	$146.41	194
Louisiana	4,779	$182.00	$152.45	207
West Virginia	3,992	$158.01	$129.47	169
Colorado	3,750	$158.18	$153.83	199
Connecticut	3,438	$211.05	$152.45	176
Oregon	3,331	$167.65	$151.53	178
Nebraska	3,227	$150.12	$149.14	152
New Hampshire	3,018	$153.86	$119.37	153
Nevada	2,467	$190.88	$152.91	122
Montana	2,374	$123.67	$130.35	99
South Dakota	1,637	$144.57	$116.02	78
Utah	1,620	$188.46	$151.59	79
Idaho	1,233	$145.79	$119.22	61
North Dakota	945	$117.42	$113.11	44
New Mexico	851	$183.00	$146.53	46
Maine	785	$112.04	$120.93	46
Rhode Island	703	$159.12	$152.92	37
Hawaii	674	$177.81	$148.06	33
Wyoming	599	$189.39	$149.25	29
Alaska	489	$238.17	$145.48	17
Vermont	284	$149.44	$115.95	16
District of Columbia	193	$216.45	$152.90	11
Guam	89	$188.03	$150.85	3
XX	61	$193.90	$145.19	3
AP	52	$187.80	$155.95	1
Puerto Rico	12	$206.05	$162.07	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.