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Reimbursement estimator

Assumptions, data sources, and disclosures

How the estimates are calculated

Until a county is chosen, the calculator uses the CY 2026 national Medicare payment amount; once a county is selected, figures reflect the Medicare payment locality that contains it, and the national figures move to the labelled benchmark strip. One shared basket of CPT units drives every figure on the page: the estimate panel, the national benchmark, the comparison line, and the proforma table.

Estimates apply the collection percentage you enter to the Medicare allowed amounts. The default of 80 percent is the Medicare program share before sequestration; the remaining 20 percent is beneficiary coinsurance that is often paid by a secondary payer, and a sequestration reduction applies to the Medicare share. Enter 100 to include the full allowed amount. Figures are Medicare allowed amounts, not collections and not a guarantee of payment. Medicare Advantage and commercial payer rates differ by contract. Code 99453 is a one time setup service billed at enrollment and is shown outside the monthly totals.

Billing rules to review

Codes 99445 and 99454 are mutually exclusive within a month, as are 99470 and 99457. Add on codes 99458 and 99439 require documented time and services. CPT instructions restrict reporting 99091 in the same month as 99457 for the same patient. Review unit selections with your coding team before relying on combined totals.

Data sources and effective dates

Rates are CY 2026 Medicare Physician Fee Schedule nonfacility amounts using the nonqualifying APM conversion factor of 33.4009, built from the CMS RVU26C July 2026 release (PPRRVU2026, GPCI2026 Addendum E with the statutory 1.0 work GPCI floor, and the 26LOCCO county crosswalk) and the U.S. Census Bureau 2025 national counties gazetteer. Amounts are effective January 1, 2026 and update each January. Locality prices for code 99091 are refreshed at page load from a file derived from CMS data. Source: CMS Physician Fee Schedule files.

Disclaimer

This tool is informational only and is not billing, coding, legal, or financial advice. It does not establish or guarantee payment for any service. Verify current requirements against the CPT code set and your Medicare Administrative Contractor before billing.