How much does Medicare pay for CPT 99496?

Medicare allowed an average of $252.87 per service and paid $197.86 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $490.89, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 99496?

Transitional care management services for problem of high complexity. It was billed 456,301 times to 399,393 Medicare beneficiaries by 16,135 providers in 2024.

Does 99496 pay differently in an office than a hospital?

Yes. The allowed amount averaged $256.10 in an office setting and $178.29 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 99496 most?

Internal Medicine, with 174,837 services from 6,002 clinicians. Next are Family Practice, Nurse Practitioner, Physician Assistant.

CPT 99496

Transitional care management services for problem of high complexity

$252.87Medicare-allowed amount per service, averaged across 456,301 services

Providers submitted

$490.89

Asking price, not received

Medicare allowed

$252.87

The fee schedule figure

Medicare paid

$197.86

Balance is patient coinsurance

Providers submitted an average of $490.89 for this code and Medicare allowed $252.87 — 1.9× 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 $197.86 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $256.10
Hospital / facility: $178.29

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. 437,349 services were billed in an office setting and 18,952 in a facility.

Services: 456,301
Beneficiaries: 399,393
Providers billing it: 16,135
Total allowed: $115,384,834

What Medicare pays for CPT 99496

Across 456,301 services billed by 16,135 providers to 399,393 beneficiaries, Medicare allowed an average of $252.87 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 99496

Specialty	Services	Beneficiaries	Avg allowed	Providers
Internal Medicine	174,837	150,512	$264.42	6,002
Family Practice	124,924	109,301	$258.76	4,996
Nurse Practitioner	100,869	89,814	$223.77	3,031
Physician Assistant	15,664	14,199	$219.47	716
Cardiology	10,814	9,740	$284.12	359
Nephrology	6,259	5,300	$259.91	269
Geriatric Medicine	3,794	3,250	$266.18	121
General Practice	3,733	3,188	$264.65	133
Hospitalist	2,735	2,489	$242.40	68
Hematology-Oncology	2,347	2,083	$272.63	106
Pulmonary Disease	1,442	1,319	$281.41	61
Emergency Medicine	1,160	1,027	$263.15	28
Interventional Cardiology	1,103	1,037	$291.71	46
Infectious Disease	1,012	966	$262.24	37
Pediatric Medicine	843	781	$282.76	19

99496 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	81,862	$252.42	$205.09	2,338
California	51,835	$274.52	$204.19	1,425
Texas	31,939	$249.53	$202.15	1,033
Pennsylvania	23,023	$250.37	$208.73	984
New York	22,826	$284.39	$206.07	810
New Jersey	18,468	$266.20	$208.57	665
Maryland	16,955	$273.62	$206.21	598
Illinois	16,307	$265.14	$205.68	632
Virginia	14,812	$245.66	$196.20	583
Michigan	12,776	$246.09	$206.50	530
Massachusetts	12,144	$268.77	$203.64	490
Arizona	11,566	$246.63	$200.01	377
North Carolina	11,178	$243.43	$203.40	470
Ohio	10,536	$224.12	$201.12	509
Tennessee	10,121	$237.38	$200.64	362
Georgia	9,674	$241.45	$201.66	331
Mississippi	8,077	$222.03	$189.14	161
Indiana	7,960	$245.22	$204.62	359
Alabama	7,528	$243.09	$208.41	301
South Carolina	7,393	$244.25	$205.25	298
Arkansas	6,244	$212.92	$202.87	226
Louisiana	6,010	$243.35	$207.76	234
Nevada	5,212	$240.47	$196.89	132
Oklahoma	4,679	$219.75	$200.41	165
Wisconsin	4,051	$231.80	$189.95	194
Washington	3,587	$254.09	$194.53	181
Delaware	3,538	$254.33	$207.96	124
Connecticut	3,409	$281.96	$207.36	157
Nebraska	3,387	$188.50	$194.38	146
Kentucky	3,349	$245.12	$206.27	143
Missouri	3,329	$231.14	$200.07	159
Iowa	2,561	$241.41	$199.70	110
Colorado	2,149	$221.70	$204.36	114
Kansas	2,125	$212.99	$192.29	96
West Virginia	2,109	$220.22	$187.35	97
Oregon	1,804	$231.43	$201.32	95
New Hampshire	1,479	$244.58	$193.10	68
Utah	1,329	$253.08	$206.68	55
New Mexico	1,252	$248.62	$203.48	45
Hawaii	1,226	$266.36	$212.73	47
Minnesota	1,159	$221.38	$177.52	61
Idaho	1,031	$222.37	$183.90	45
District of Columbia	786	$298.49	$214.38	24
Montana	601	$205.98	$191.89	28
South Dakota	546	$190.86	$156.03	24
Rhode Island	523	$257.33	$214.71	28
Maine	428	$212.12	$183.69	15
North Dakota	362	$159.83	$144.98	21
Wyoming	334	$252.57	$202.02	16
Vermont	236	$254.52	$198.48	12
Alaska	207	$304.03	$191.33	12
XX	180	$232.62	$184.39	1
Guam	79	$272.44	$198.47	3
Puerto Rico	20	$278.22	$209.28	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
99426Principal care management services for a single high-risk disease$60.08
99484Care management services for behavioral health conditions$50.05

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.