Medicare Pays an NP 85% of the Fee Schedule: What 99214 Collects

Does Medicare pay nurse practitioners 85 percent of the fee schedule?

Yes. Since January 1, 1998, the Medicare allowed amount for a nurse practitioner's service may not exceed 85 percent of the physician fee schedule amount for the same service, under 42 CFR 414.56(c) 1Ref 1Office of the Federal Register (2026).42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services.The 85 percent ceiling itself: paragraph (c), services furnished on or after January 1, 1998, allowed amounts for an NP's services may not exceed 85 percent of the physician fee schedule amount, the parallel assistant-at-surgery clause, and the fact that the section's only amendment on record dates from November 1998.. That is a ceiling, and there is no second fee schedule written for NPs. Medicare then pays 80 percent of the lesser of your actual charge or that 85 percent figure, and the other 20 percent is the patient's coinsurance 2Ref 2Centers for Medicare & Medicaid Services (2025).Medicare and Mental Health Coverage.CMS's plain statement that it pays NP professional services at 80 percent of the lesser of the actual charge or 85 percent of the physician PFS amount, and that services furnished incident to an NP outside a hospital setting are paid at 85 percent as well..

The wording matters, and "may not exceed" is the part of it doing the work. The section does not say Medicare pays an NP 85 percent. It says the allowed amount for the NP's service cannot go above 85 percent of what the physician fee schedule would allow, and the lesser-of rule then does the rest. If your charge for the visit is lower than the ceiling, the allowed amount is your charge.

The rule has not moved in a long time. The section's earlier paragraphs are the 1992 to 1997 limits for rural areas and nursing facilities, retired when the current paragraph took effect, and the only amendment on record for the section dates from November 1998 1Ref 1Office of the Federal Register (2026).42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services.The 85 percent ceiling itself: paragraph (c), services furnished on or after January 1, 1998, allowed amounts for an NP's services may not exceed 85 percent of the physician fee schedule amount, the parallel assistant-at-surgery clause, and the fact that the section's only amendment on record dates from November 1998.. Assistant-at-surgery work has its own clause in the same section and lands in the same place: 85 percent of what the schedule would allow a physician for the assist 1Ref 1Office of the Federal Register (2026).42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services.The 85 percent ceiling itself: paragraph (c), services furnished on or after January 1, 1998, allowed amounts for an NP's services may not exceed 85 percent of the physician fee schedule amount, the parallel assistant-at-surgery clause, and the fact that the section's only amendment on record dates from November 1998..

What the 85 percent is 85 percent of

The 85 percent applies to the physician fee schedule amount, which is itself the product of three published numbers: the relative value units for the code, the geographic adjustment factor for your fee schedule area, and the conversion factor, under 42 CFR 414.20(a) 3Ref 3Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).42 CFR § 414.20 Formula for computing fee schedule amounts.The shape of the fee schedule amount the 85 percent is applied to: RVUs times the geographic adjustment factor times the conversion factor, and the 95 percent fee schedule amount for a nonparticipating supplier. No dollar values.. Change any of the three and the physician amount moves, and the NP ceiling moves with it.

The conversion factor is the one that changes on a calendar. For 2026 there are two for the first time. The final CY 2026 conversion factor for a practitioner outside a qualifying alternative payment model is $33.40. That is up a projected $1.05, or 3.26 percent, from the $32.35 factor of 2025. For a qualifying APM participant the factor is $33.57, up $1.22, or 3.77 percent. Both apply to services furnished on or after January 1, 2026 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).What the CY 2026 final rule finalized: the two conversion factors ($33.40 nonqualifying APM, $33.57 qualifying APM), their changes from the $32.35 CY 2025 factor, effective for services on or after January 1, 2026, and the new behavioral health add-on G-codes and digital mental health treatment device payment that show the code set moves year to year.. The RVU file CMS publishes carries its own copies of those figures to four decimals, 33.4009 in the standard release and 33.5675 in the qualifying-APM release 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount..

Which of the two applies to your claims depends on whether CMS counts you as a qualifying APM participant for the year. Nothing on this page can tell you that. The arithmetic below uses the lower factor, and a practice that has been told it qualifies should rerun the numbers at the higher one.

The RVU file is also a moving document. The figures here come from the January 2026 release, and CMS issues quarterly replacements through the year 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount., so a number copied from this page in October should be checked against the current file first. The same regulation sets a nonparticipating supplier's fee schedule amount at 95 percent of the participating one 3Ref 3Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).42 CFR § 414.20 Formula for computing fee schedule amounts.The shape of the fee schedule amount the 85 percent is applied to: RVUs times the geographic adjustment factor times the conversion factor, and the 95 percent fee schedule amount for a nonparticipating supplier. No dollar values.; a later section covers why an NP's services are furnished on an assignment-related basis in any case.

99214, worked from the 2026 inputs

At a geographic index of 1.000, an established-patient office visit coded 99214 carries 4.06 total non-facility RVUs in the January 2026 file: 1.92 work, 2.00 practice expense and 0.14 malpractice 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. Multiplied by the file's conversion factor of 33.4009, that is a physician amount of about $135.61. The NP ceiling at 85 percent is about $115.27. Medicare's 80 percent share of the ceiling is about $92.22, leaving about $23.05 in coinsurance.

Those dollar figures are arithmetic. CMS prints RVUs, indices and the conversion factor in the file; it prints no allowed amount for any code 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. The cents can differ from what the Medicare Physician Fee Schedule Look-Up Tool prints for your locality, because the tool applies your own indices and rounds at its own step. Before you build a budget on a national figure, put your locality into that tool and read the number it prints.

Medicare's own check comes to 68 percent of the physician amount. On that national 99214 it is $92.22 against $135.61, because the 20 percent coinsurance comes out of the ceiling before the payment leaves CMS. The other 17 points are the patient's, and collecting them is your job at the front desk.

Place of service changes the RVUs before anything else does. The same 99214 furnished in a facility, a hospital outpatient department for example, carries 2.53 total RVUs, because the practice expense component drops from 2.00 to 0.47 when the facility bears the overhead 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. That is a physician amount of about $84.50 and an NP ceiling of about $71.83. Know which of the two your claim will price at before you sign a lease in a hospital-owned building.

Geography moves the number before the 85 percent does

The 85 percent is the last multiplication, and the geographic indices come first, so two NPs billing the same 99214 in the same month collect different ceilings by state and locality. In Alabama, locality 00, the CY 2026 file's indices compute to a physician amount of about $125.23 and an NP ceiling of about $106.44 for non-facility 99214 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. In Manhattan the same code computes to about $153.27, with an NP ceiling of about $130.28.

That is roughly $24 of difference on one visit code, before either NP has done anything different. Alabama's 2026 indices are 1.000 for work, with the floor applied, 0.875 for practice expense and 0.566 for malpractice; Manhattan's are 1.064, 1.162 and 1.586 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. The malpractice index swings widest, though it multiplies the smallest RVU component.

The lookup takes ten minutes and should be done once a year. Addendum E of the RVU file, the GPCI table, lists every state and Medicare locality with its three indices 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. Multiply the work RVU by the work index, the practice expense RVU by the practice expense index, the malpractice RVU by the malpractice index, add the three, and multiply the sum by the conversion factor. That product is your physician amount, and 85 percent of it is your ceiling. The Look-Up Tool does the same arithmetic and prints the result.

The codes a solo NP bills most, at the 85 percent ceiling

The table below runs the same arithmetic at a geographic index of 1.000, for the visit and psychotherapy codes a solo NP practice bills most: total non-facility RVUs from the January 2026 file, the physician amount at the 33.4009 conversion factor, the NP ceiling at 85 percent, and Medicare's 80 percent share of the ceiling 5Ref 5Centers for Medicare & Medicaid Services (2026).RVU26A — 2026 National Physician Fee Schedule Relative Value File January Release.The CY 2026 January-release RVU inputs for 99214 (1.92 work, 2.00 non-facility and 0.47 facility practice expense, 0.14 malpractice; 4.06 non-facility and 2.53 facility totals), the non-facility totals for 99213, 99215, 99204, 90791, 90834 and 90837, the file's own conversion factor of 33.4009 (33.5675 in the QPP release), and the Addendum E GPCIs for Alabama locality 00 and Manhattan. Every dollar figure in the article is arithmetic on these inputs; the file prints no allowed amount.. Every figure is computed from the published inputs, none is printed by CMS, and your locality's indices will move every row.

The last column is the check that will clear. The column before it is the number you post as the allowed amount, and the gap between them is what you collect from the patient, after the annual Part B deductible has been met for the year.

The code set moves too. The CY 2026 final rule added three behavioral health add-on G-codes, comparable to the collaborative care and behavioral health integration codes, for use when the advanced primary care management base code is reported, and expanded payment for digital mental health treatment devices 4Ref 4Centers for Medicare & Medicaid Services (2025).Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F).What the CY 2026 final rule finalized: the two conversion factors ($33.40 nonqualifying APM, $33.57 qualifying APM), their changes from the $32.35 CY 2025 factor, effective for services on or after January 1, 2026, and the new behavioral health add-on G-codes and digital mental health treatment device payment that show the code set moves year to year.. None of that changes the 85 percent. It does change the base the 85 percent is applied to.

Why you cannot bill around the ceiling

Medicare pays an NP only for services the NP personally performed, on an assignment-related basis, and the NP may not charge the patient more than the assignment rules permit, under 42 CFR 410.75(e) 6Ref 6Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).§ 410.75 Nurse practitioners' services..Paragraph (e): an NP is paid only for professional services personally performed, supervising other nonphysician staff does not count, no facility or other provider may be paid for the same professional service, NP services are furnished on an assignment-related basis, the NP may not charge a beneficiary more than 42 CFR 424.55 permits, and excess collected must be refunded in full.. Accepting assignment means taking the approved amount as your full charge and collecting from the patient only the difference between that amount and Medicare's payment, the deductible and coinsurance, under 42 CFR 424.55 7Ref 7Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).42 CFR § 424.55 Payment to the supplier.What accepting assignment obliges: accept the Medicare approved amount as the full charge and collect from the beneficiary only the difference between the approved amount and the Part B payment, the deductible and coinsurance.. No balance bill recovers the 15 percent.

Your charge master still matters, in one direction. Medicare allows the lesser of your actual charge or the 85 percent ceiling 2Ref 2Centers for Medicare & Medicaid Services (2025).Medicare and Mental Health Coverage.CMS's plain statement that it pays NP professional services at 80 percent of the lesser of the actual charge or 85 percent of the physician PFS amount, and that services furnished incident to an NP outside a hospital setting are paid at 85 percent as well., so a charge set below the ceiling lowers what you are paid, and a charge set above it changes nothing. A practice that priced 99214 at $100 in 2026 would be allowed $100 at the national inputs, and would have handed back about $15 on every visit.

Money collected above the permitted amount has to go back. The regulation says an NP who collects more than the assignment rules permit must refund the excess in full 6Ref 6Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).§ 410.75 Nurse practitioners' services..Paragraph (e): an NP is paid only for professional services personally performed, supervising other nonphysician staff does not count, no facility or other provider may be paid for the same professional service, NP services are furnished on an assignment-related basis, the NP may not charge a beneficiary more than 42 CFR 424.55 permits, and excess collected must be refunded in full., and it is the kind of rule that surfaces in an audit long after the front desk forgot the overcharge.

Personal performance is the other half of 42 CFR 410.75(e), and it is stricter than it sounds. Supervising other nonphysician staff does not count as personally performing the service, and no facility or other provider may be paid for furnishing the same professional service 6Ref 6Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).§ 410.75 Nurse practitioners' services..Paragraph (e): an NP is paid only for professional services personally performed, supervising other nonphysician staff does not count, no facility or other provider may be paid for the same professional service, NP services are furnished on an assignment-related basis, the NP may not charge a beneficiary more than 42 CFR 424.55 permits, and excess collected must be refunded in full.. The rendering practitioner on the claim is the person who did the work.

None of it pays until enrollment clears. The CMS-855I is the form, and Medicare 855I enrollment processing time is its own question with its own calendar.

The incident-to fork, and why it is closed to a solo NP

Under Medicare, the incident-to route bills the service under a physician rather than under the NP 8Ref 8Centers for Medicare & Medicaid Services (2026).Incident To Services & Supplies.The conditions attached to the Medicare incident-to route: an initial service personally performed by the billing physician, continued involvement, direct supervision, the expense borne by the billing practitioner, services of a kind commonly furnished in that office, and the rule that only that physician may bill. Medicare only., and the same service billed under an NP's own NPI pays at the 85 percent ceiling 1Ref 1Office of the Federal Register (2026).42 CFR 414.56 — Payment for nurse practitioners' and clinical nurse specialists' services.The 85 percent ceiling itself: paragraph (c), services furnished on or after January 1, 1998, allowed amounts for an NP's services may not exceed 85 percent of the physician fee schedule amount, the parallel assistant-at-surgery clause, and the fact that the section's only amendment on record dates from November 1998.. But that route needs a physician who performed an initial service, stays involved and directly supervises, and only that physician may bill 8Ref 8Centers for Medicare & Medicaid Services (2026).Incident To Services & Supplies.The conditions attached to the Medicare incident-to route: an initial service personally performed by the billing physician, continued involvement, direct supervision, the expense borne by the billing practitioner, services of a kind commonly furnished in that office, and the rule that only that physician may bill. Medicare only.. A practice that is one NP and no physician has nobody to satisfy those conditions.

That is the whole of why a solo NP-owned practice bills at 85 percent. The incident-to provision was written around a physician's professional service, with the auxiliary work folded into the physician's bill, and its conditions all point back at that physician: the initial service, the continuing involvement, the direct supervision, the expense borne by the billing practitioner, and the requirement that the services be the kind commonly furnished in that office 8Ref 8Centers for Medicare & Medicaid Services (2026).Incident To Services & Supplies.The conditions attached to the Medicare incident-to route: an initial service personally performed by the billing physician, continued involvement, direct supervision, the expense borne by the billing practitioner, services of a kind commonly furnished in that office, and the rule that only that physician may bill. Medicare only.. Remove the physician and the provision has nothing to attach to.

An NP can be the supervising practitioner too, and the rate follows the supervisor. CMS pays services furnished incident to an NP's services, outside a hospital setting, at 85 percent of the physician amount, the same rate as the NP's own professional services 2Ref 2Centers for Medicare & Medicaid Services (2025).Medicare and Mental Health Coverage.CMS's plain statement that it pays NP professional services at 80 percent of the lesser of the actual charge or 85 percent of the physician PFS amount, and that services furnished incident to an NP outside a hospital setting are paid at 85 percent as well.. Hiring a nurse or a medical assistant under your supervision extends your 85 percent to their work. It does not lift the rate.

Incident-to and personal performance are different provisions: the first lets a supervisor bill for auxiliary staff under conditions, the second says an NP's own professional services must be the NP's own work, and confusing them is how a rendering-provider error gets written. And all of this is Medicare. A commercial plan writes its own incident-to terms, and its contract is the document that governs them.

Where the 85 percent stops: commercial contracts and Medicaid

The 85 percent is a Medicare Part B rule and binds no other payer. A commercial plan pays an NP whatever its contract says, which may be 85 percent of its own physician rate, or 100 percent, or a figure of its own, and the federal regulations supply no number for that. Medicaid is set state by state, and your state Medicaid program's own bulletin is where that figure lives.

The contract language is worth reading closely, because it often borrows Medicare's. When a payer's fee exhibit says non-physician practitioners are reimbursed at 85 percent of the physician fee schedule, it is copying a federal practitioner class: the identical ceiling covers physician assistants on the same terms as NPs, for services furnished on or after January 1, 1998, in 42 CFR 414.52(d) 9Ref 9Office of the Federal Register / Centers for Medicare & Medicaid Services (2026).42 CFR 414.52 — Payment for physician assistants' services..Paragraph (d): the identical 85 percent ceiling applies to physician assistants' services furnished on or after January 1, 1998, which is why a contract clause naming non-physician practitioners is copying a federal practitioner class.. Medicare fixes that base; the 85% clause in commercial contracts does not. What it leaves open is the payer's own physician schedule, which may sit anywhere relative to Medicare's.

Medicaid works from a different base again. New York is one dated example. Its Medicaid program benchmarked fee-for-service physician fees to 80 percent of then-current Medicare non-facility rates, then set NP fees at 95 percent of those physician fees, effective October 1, 2023, across the Medicine, Drug, Surgery and Radiology schedules 10Ref 10New York State Department of Health, Office of Health Insurance Programs (2023).New York State Medicaid Update - August 2023 Volume 39 - Number 13.New York only, as a dated example: the state Medicaid program benchmarked fee-for-service physician fees to 80 percent of then-current Medicare non-facility rates and NP fees to 95 percent of those physician fees, effective October 1, 2023, across the Medicine, Drug, Surgery and Radiology schedules.. That is one state on one date, and a later bulletin or an enacted budget can move either benchmark. New York shows the shape, though: a state's own percentage of a state's own physician fee, published in a state's own Medicaid bulletin. Your state Medicaid's NP payment percentage is found the same way, in the NP provider manual and fee schedule your state's program publishes.

Other Medicare disciplines are paid off a percentage of a different base entirely, and the Medicare 75% rate for LCSWs is its own question with its own arithmetic. A practice that adds a therapist to an NP is billing two ceilings off two bases.

So carry the method out of this page. Look up the RVUs and your locality's indices in the current file, multiply through at this year's conversion factor, take 85 percent, and expect Medicare's check to be 80 percent of that. Every other payer starts a new calculation.