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Coordinate with the treating practice while keeping agency services and professional care-management work distinct.
Begin with the home-health plan of care, existing agency services and treating practitioner’s responsibilities. Review whether proposed support adds distinct, necessary care rather than repeating existing work.
Current home-health episode and plan of care.
Explore documentation, revenue-cycle and agreed staffing support around your existing care model.
Agency, practitioner and outside-team tasks and documentation.
Do not treat the agency’s episode payment and a practitioner’s possible Part B claim as interchangeable revenue. Review coverage and duplication first; model each organization’s own payment route.
Validate the specific service, payer and arrangement before forecasting additional revenue.
Scenarios to evaluate—not approvals to bill or revenue guarantees.
Do not treat the agency’s episode payment and a practitioner’s possible Part B claim as interchangeable revenue. Review coverage and duplication first; model each organization’s own payment route.
Check enrollment, the exact service, stay dates, place of service and existing services. A Part A stay and care after discharge are different situations.
MEDICARE RATE REFERENCES · OCTOBER–DECEMBER 2026
All 58 counties. Nine program families. No NPI, email or Navigator assessment required. These are selected service references—not complete program bundles or a recommendation to bill codes together.
CMS locality: SAN FRANCISCO-OAKLAND-BERKELEY (SAN FRANCISCO/SAN MATEO/ALAMEDA/CONTRA COSTA CNTY) · MAC 01112 · locality 05
A building name does not determine the claim’s place of service. A facility rate does not establish that a code is billable during an inpatient or Part A SNF stay.
| Code and plain-English service | Medicare allowed amount | Illustrative Medicare portion | Standard 20% cost share |
|---|---|---|---|
| RPM · 99454 Remote Physiologic Monitoring: connected device supply and transmission of readings on 16–30 days in a 30-day period. | $73.14 | $57.3480%, then 2% sequestration | $14.63Not automatically collectible |
| RPM · 99457 Remote Physiologic Monitoring: first 20 minutes of qualifying monthly treatment management, including interactive communication. | $65.26 | $51.1680%, then 2% sequestration | $13.05Not automatically collectible |
| CCM · 99490 Chronic Care Management: first 20 minutes of qualifying clinical-staff care coordination for multiple chronic conditions. | $80.42 | $63.0580%, then 2% sequestration | $16.08Not automatically collectible |
| PCM · 99426 Principal Care Management: first 30 minutes of qualifying clinical-staff management of one complex chronic condition. | $82.78 | $64.9080%, then 2% sequestration | $16.56Not automatically collectible |
| APCM · G0556 Advanced Primary Care Management: monthly Level 1 service, requiring the complete applicable primary-care service model. | $19.79 | $15.5280%, then 2% sequestration | $3.96Not automatically collectible |
| TCM · 99495 Transitional Care Management: a qualifying 30-day transition, timely contact, moderate medical decision-making and a visit within 14 days. | $274.86 | $215.4980%, then 2% sequestration | $54.97Not automatically collectible |
| BHI · 99484 General Behavioral Health Integration: at least 20 minutes of qualifying monthly clinical-staff behavioral-health care management. | $69.25 | $54.2980%, then 2% sequestration | $13.85Not automatically collectible |
| RTM · 98977 Remote Therapeutic Monitoring: qualifying musculoskeletal device supply and therapeutic data transmission; management is a separate service. | $72.20 | $56.6080%, then 2% sequestration | $14.44Not automatically collectible |
| PIN · G0023 Principal Illness Navigation: first 60 minutes of qualifying monthly navigation for a serious high-risk condition. | $110.09 | $86.3180%, then 2% sequestration | $22.02Not automatically collectible |
| CPM · G3002 Chronic Pain Management: first 30 minutes of qualifying practitioner-personal monthly pain management; not a nurse-only service. | $102.30 | $80.2080%, then 2% sequestration | $20.46Not automatically collectible |
The allowed amount is a fee-schedule reference, not guaranteed collections. The Medicare portion assumes the deductible is met, assigned claims and no other adjustments. For a $100 allowed amount, the standard split is $80 Medicare and $20 cost sharing; 2% sequestration reduces Medicare’s $80 to $78.40.
Secondary insurance, Medicaid crossover, deductible status and claim-level adjustments change actual collections. QMB patients cannot be billed Medicare cost sharing even when Medicaid pays nothing. Medicare Advantage and commercial rates depend on the actual plan and contract. The higher QP conversion factor is not modelled here.
Patient cost-share guide →Verified against CMS October RVUs and GPCIs (RVU26D) and the annual carrier file: 580 locality/code/setting comparisons. October revisions did not change these services. Effective 2026-10-01 through 2026-12-31. Descriptions are plain-language summaries, not full coding instructions. CMS source release. Requirements and sources.
This public lookup covers California only. Do not apply these amounts to Florida or another state. A rate reference is not a facility revenue estimate.
Define outreach, documentation, staffing and billing handoffs around your existing care. Clinical decisions remain with the responsible professionals.
Service hours, review cadence, urgent contacts and after-hours responsibilities are agreed before enrollment. PrimeVital does not promise continuous device surveillance or a 24/7 nurse line on this website. Emergency symptoms require emergency services, not waiting for routine monitoring review.
No upfront pilot fee; service fees are paid from collections under the written agreement. Confirm fees, timing and insufficient-collection terms before launch.
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