CPT (Current Procedural Terminology) codes are five-digit numbers that describe every medical service or procedure. Your doctor, hospital, and insurance company use them to communicate exactly what was done. Every line on your medical bill has a CPT code, and knowing the code lets you look up what Medicare pays for that same service.

Why do providers charge so much more than Medicare pays?

Providers set their own "chargemaster" prices, which are essentially list prices. Medicare pays a fixed rate based on the resources each service actually requires (the RVU system for procedures, or the Clinical Lab Fee Schedule for lab tests). Commercial insurers typically pay 150% to 250% of Medicare rates. Uninsured patients are often billed the full chargemaster price, which can be 2x to 30x what Medicare pays.

Can I use Medicare rates to negotiate my bill?

Yes. Medicare rates are the closest thing to a "fair price" benchmark in U.S. healthcare. When negotiating, ask the provider what they accept from Medicare for the same CPT code. Most providers will accept 150% to 200% of Medicare for cash-pay patients, which is still far less than their chargemaster price. Many hospital financial assistance policies also use a multiple of Medicare as their discount floor.

How are Medicare rates calculated?

For most procedures, Medicare uses the Resource-Based Relative Value Scale (RBRVS). Each CPT code gets three RVU components: Work (physician time and skill), Practice Expense (overhead), and Malpractice. These are multiplied by geographic adjustment factors (GPCIs) and a conversion factor ($33.4009 in 2026). Lab tests (80000-89999 range) use a separate Clinical Laboratory Fee Schedule with flat national rates.

CPT 99490

Chronic Care Management, First 20 Minutes Per Month

CPT 99490 is a monthly recurring charge for managing patients with two or more chronic conditions. Providers charge an average of $106.88, while Medicare pays $66.13 (1.6x markup). This charge appears on your Medicare statement every month, even if you never spoke to your doctor that month. The 20 minutes of "care management" can be performed entirely by clinical staff behind the scenes.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 99490 at a Glance

Average provider charge: $106.88
Medicare rate (office): $66.13
Medicare rate (facility): $66.13
Typical markup: 1.6x over Medicare rate

Time requirement: 20 minutes per month
Billing frequency: Monthly (recurring)
Beneficiaries (2023): 1.16 million
Annual cost to patient (Medicare): ~$159

How the Medicare Rate Is Calculated

Medicare values every procedure using Relative Value Units (RVUs) across three components, then multiplies by a national conversion factor of $33.4009 (2026). Here is the exact math for chronic care management:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Physician oversight and supervision	0.61	0.61
Practice Expense RVU	Staff time, technology, care coordination	1.28	1.28
Malpractice RVU	Professional liability insurance	0.09	0.09
Total RVU		1.98	1.98
x $33.4009	2026 conversion factor	$66.13	$66.13

Notice the high Practice Expense RVU: The practice expense (1.28) is more than double the work RVU (0.61). This reflects the reality that most CCM work is done by clinical staff (nurses, care coordinators), not the physician. The physician provides oversight, but the hands-on coordination is delegated.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same monthly CCM charge pays differently by state, ranging from about $52 in Arkansas to $61 in Alaska.

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$55.73	$106.88	1.9x
California (Los Angeles)	$57.32	$106.88	1.9x
New York (Manhattan)	$58.01	$106.88	1.8x
Florida (Fort Lauderdale)	$55.28	$106.88	1.9x
Ohio	$53.28	$106.88	2.0x
Mississippi	$51.79	$106.88	2.1x
Arkansas	$51.64	$106.88	2.1x
Alaska	$60.65	$106.88	1.8x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $106.88 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for Chronic Care Management

Because CCM is billed monthly, the cost compounds over time. Even a modest coinsurance adds up to a meaningful annual expense for patients who may not have realized they were enrolled.

Your Situation	Monthly Cost	Annual Cost (12 months)
Medicare Part B (20% coinsurance)	$13.23	$158.76
Medicare with Medigap (Plan F or G)	$0	$0 (supplement covers coinsurance)
Medicare Advantage	$0 to $20	$0 to $240
Commercial insurance (copay plan)	$15 to $40	$180 to $480
High-deductible plan (not met)	$65 to $107	$780 to $1,284

Key point: consent is required. Medicare requires your verbal consent before a provider can enroll you in chronic care management. You should have been informed that you would receive monthly charges and that you can opt out at any time. If you are seeing 99490 on your Medicare Summary Notice and never agreed to it, call your doctor's office immediately.

Is Chronic Care Management Worth the Cost?

The question for most patients is not "insurance vs. cash" (there is no cash-pay equivalent), but rather "should I stay enrolled or opt out?" Here is how to evaluate whether CCM is providing value:

When CCM Provides Value

You have multiple chronic conditions requiring coordination between specialists
You receive proactive phone calls, medication reviews, or care plan updates
Your care coordinator helps you schedule appointments and follow up on referrals
You notice fewer gaps in care, fewer ER visits, or better medication management

When You Should Consider Opting Out

You never receive calls, messages, or visible coordination from the practice
You were enrolled without clear explanation of what you would receive
Your conditions are well-managed and you do not need between-visit support
The monthly coinsurance is a financial burden with no perceived benefit

The transparency problem: Many patients enrolled in CCM never see or feel the care coordination happening. The work (reviewing charts, sending referral notes, calling pharmacies) happens behind the scenes. Ask your provider for a monthly summary of what CCM activities were performed on your behalf. If they cannot tell you, question whether the 20 minutes of documented time is genuinely occurring.

Common Billing Problems with 99490

Enrolled without informed consent

Medicare requires that patients give verbal consent before being billed for CCM. Some practices obtain consent through vague paperwork during check-in, or enroll patients without a clear explanation of the recurring charges. If you did not knowingly agree to monthly care management and are seeing 99490 charges, call the practice to revoke consent and request a refund for months when you were unaware of enrollment.

Billed by multiple providers in the same month

Medicare allows only one provider to bill 99490 per patient per month. If two different practices are both charging CCM for you, one of those claims should be denied. Check your Medicare Summary Notice for duplicate CCM charges from different providers. If both are being paid, report this to Medicare (1-800-MEDICARE).

No documented 20 minutes of service

To bill 99490, clinical staff must spend at least 20 minutes per month on care management activities. Some practices use automated systems or templates that generate minimal documentation without genuine coordination. If you request your care management records and find only generic notes with no specific actions taken, the billing may not be supported. You can file a complaint with Medicare if you believe services were not rendered.

Patient does not meet the two-chronic-condition requirement

CCM requires that the patient have two or more chronic conditions expected to last at least 12 months (or until death) that place the patient at significant risk of death, acute exacerbation, or functional decline. Common qualifying pairs include diabetes and hypertension, COPD and heart failure, or depression and chronic pain. If you have only one chronic condition, 99490 is not billable for you.

Related Care Management Codes

Code	Description	Time/Month	Medicare Rate	Avg. Charge
99490	Chronic care management (basic)	20 min	$66.13	$106.88
99491	CCM, physician-directed (complex)	30 min	$96.51	$155.00
99487	Complex CCM, first 60 min	60 min	$131.89	$210.00
99497	Advance care planning, first 30 min	30 min	$86.84	$159.77
99426	Principal care management, first 30 min	30 min	$65.14	$105.00

Frequently Asked Questions

What is chronic care management (CPT 99490)?

CPT 99490 covers the first 20 minutes per month of clinical staff time managing care for patients with two or more chronic conditions expected to last at least 12 months. This includes care coordination, medication management, communicating with other providers, and updating care plans. The work can be performed by nurses or care coordinators under physician supervision.

Why am I being charged monthly for 99490 when I did not see my doctor?

CPT 99490 does not require a face-to-face visit. It covers behind-the-scenes care coordination such as reviewing lab results, coordinating referrals, updating care plans, and communicating with pharmacies or specialists. However, you must have given verbal consent to be enrolled. If you never agreed to this service or want to stop the charges, call your doctor's office to revoke your consent and opt out.

How much does Medicare charge for chronic care management?

Medicare pays $66.13 per month for CPT 99490. Patients with original Medicare Part B owe 20% coinsurance ($13.23 per month, or about $159 per year) after their annual Part B deductible is met. If you have a Medigap supplement (Plan F, G, or similar), the supplement typically covers this coinsurance, making your cost $0.

Can I opt out of chronic care management?

Yes. You can opt out of chronic care management at any time by calling your doctor's office and revoking your consent. Once you opt out, the monthly 99490 charges will stop at the end of that billing period. You can only be billed by one CCM provider per month, and your consent must be documented in your medical record. Opting out does not affect your other medical care with that provider.

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