What Are Medicare Reimbursement Rates for 2026?
Quick Answer
Key 2026 Medicare reimbursement rates (national averages): E&M established patient: 99213 ~$92, 99214 ~$130, 99215 ~$184. CCM: 99490 ~$66, 99439 ~$47, 99491 ~$94. RPM: 99453 ~$19, 99454 ~$56, 99457 ~$49, 99458 ~$39. BHI: 99484 ~$49. AWV: G0438 ~$175, G0439 ~$119. Advance Care Planning: 99497 ~$86. These are national average allowed amounts — actual reimbursement varies by geographic locality (GPCI adjustment), with urban areas typically 5-15% higher than national averages and rural areas 5-10% lower. The 2026 Medicare conversion factor is approximately $32.35 per RVU. CMS publishes the complete fee schedule annually, with proposed rules in July and final rules in November of the preceding year. Source: NPIxray analysis of 1.175M Medicare providers and 8.15M billing records.
E&M Office Visit Rates
Established patient E&M codes (the most commonly billed codes in outpatient medicine): 99211 (May not require physician presence) ~$25. 99212 (Straightforward MDM) ~$57. 99213 (Low MDM) ~$92. 99214 (Moderate MDM) ~$130. 99215 (High MDM) ~$184. 99417 (Prolonged services, each additional 15 min beyond 99215) ~$67.
New patient E&M codes: 99202 (Straightforward MDM) ~$80. 99203 (Low MDM) ~$131. 99204 (Moderate MDM) ~$196. 99205 (High MDM) ~$262.
These rates represent the total Medicare allowed amount. Medicare Part B pays 80%, and the patient is responsible for 20% coinsurance (after meeting the Part B deductible). For 99214 at $130 allowed: Medicare pays $104, patient owes $26.
Care Management Code Rates
CCM (Chronic Care Management): 99490 (20 min clinical staff, non-complex) ~$66. 99439 (Each additional 20 min, non-complex, max 2 units) ~$47. 99491 (30 min physician/QHP, complex) ~$94. 99437 (Each additional 30 min, complex) ~$63.
RPM (Remote Patient Monitoring): 99453 (Device setup and patient education, one-time) ~$19. 99454 (Device supply, 16+ days transmission) ~$56/month. 99457 (First 20 min interactive communication) ~$49/month. 99458 (Each additional 20 min communication) ~$39/month.
BHI (Behavioral Health Integration): 99484 (General BHI, 20+ min) ~$49/month. 99492 (CoCM initial month, 70+ min) ~$164. 99493 (CoCM subsequent, 60+ min) ~$130/month. 99494 (CoCM additional 30 min) ~$67.
Preventive Service Rates
Annual Wellness Visit: G0438 (Initial AWV) ~$175. G0439 (Subsequent AWV) ~$119. G0402 (Welcome to Medicare/IPPE) ~$175. All AWV codes have zero patient cost-sharing.
Other preventive services commonly billed with the AWV: 99497 (Advance Care Planning, first 30 min) ~$86. 99498 (ACP, each additional 30 min) ~$75. G0444 (Depression screening) ~$19. G0442 (Alcohol screening) ~$19. G0443 (Alcohol counseling) ~$29. 99406 (Tobacco cessation counseling, 3-10 min) ~$16. 99407 (Tobacco cessation counseling, >10 min) ~$30.
Layering these services during an AWV visit: G0439 ($119) + 99497 ($86) + 99214-25 ($130) = $335 per encounter, with the AWV portion having zero patient copay.
Geographic Adjustments (GPCI)
Medicare adjusts reimbursement by geographic locality through the Geographic Practice Cost Index (GPCI). The GPCI has three components: physician work, practice expense, and malpractice. Each locality has its own GPCI multiplier.
High-reimbursement areas (approximate adjustment): San Francisco (+12-15%), New York City (+10-14%), Los Angeles (+8-12%), Boston (+7-11%), Chicago (+5-8%). Low-reimbursement areas: Rural Mississippi (-8-12%), Rural Alabama (-6-10%), Rural Iowa (-5-8%).
To calculate your locality-specific rate: multiply the national average by your locality's blended GPCI factor. For example, 99214 at $130 national x 1.12 (San Francisco GPCI) = approximately $146 in San Francisco. NPIxray adjusts for geographic differences when calculating your revenue benchmarks and gap analysis.
How Rates Are Determined
Medicare reimbursement rates are calculated using the formula: Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x Conversion Factor. The 2026 conversion factor is approximately $32.35.
RVUs (Relative Value Units) are set by the AMA's RUC (Relative Value Scale Update Committee) and finalized by CMS. The conversion factor is adjusted annually based on Congressional legislation, budget neutrality requirements, and the Medicare Economic Index. Rates are published in the Medicare Physician Fee Schedule, available at cms.gov.
Important: actual payment may differ from the fee schedule for specific situations including sequestration (currently 2% reduction), Multiple Procedure Payment Reduction (MPPR) for certain imaging and therapy services, and individual payer contracts for Medicare Advantage plans.
Frequently Asked Questions
Do Medicare reimbursement rates change every year?
Yes. CMS updates the Medicare Physician Fee Schedule annually. Changes reflect updates to RVU values, the conversion factor, and GPCI adjustments. Proposed rules are published in July and final rules in November for the following calendar year. Rate changes can be significant — the conversion factor has varied by up to 4% year to year.
Are Medicare Advantage rates the same as traditional Medicare?
Not necessarily. Medicare Advantage (MA) plans set their own reimbursement rates, which may be higher or lower than traditional Medicare. Some MA plans pay a percentage of the Medicare fee schedule (e.g., 110% of Medicare), while others negotiate their own rates. Always verify rates with each MA plan individually.
What is the Medicare sequestration reduction?
Medicare sequestration is a mandatory 2% reduction applied to all Medicare fee-for-service claims. This means actual payment is 2% less than the fee schedule amount. For example, if 99214 allows $130, the actual payment after sequestration is $127.40. Sequestration has been in effect since 2013 with brief pandemic-related pauses.
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