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Explore coordinated resident care, professional billing support and staffing without confusing facility payments with practitioner reimbursement.
Explore chronic-condition coordination (CCM), behavioral-health integration (BHI) or condition-specific management with the treating practitioner.
Confirm resident status, staff arrangements, existing services and code-specific requirements. Professional reimbursement is not automatically facility income.
Start with the existing SNF care plan and professional services—not an assumed monthly care-program bundle.
Check the exact code and covered stay dates before forecasting. A facility-rate reference is not permission to bill during the stay.
Assess transitional care management (TCM), then ongoing care coordination or clinically appropriate monitoring.
Identify the receiving practitioner, discharge date, timely contact and follow-up visit. Keep overlapping services and time distinct.
Scenarios to evaluate—not approvals to bill or revenue guarantees.
Professional Medicare allowed amounts are not revenue automatically payable to the nursing home. Validate billability before comparing facility/non-facility rates or Medicaid crossover. Any payment to the facility under a services arrangement needs separate legal review.
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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