PMHNP Practice Economics
PMHNP Reimbursement Rates: How Nurse Practitioner Payment Actually Works
Medicare allows a PMHNP billing under their own NPI up to 85 percent of the physician fee schedule (42 CFR 414.56), then pays 80 percent of that allowed amount, and the patient or a secondary payer owes the 20 percent coinsurance. For a 99214 visit in 2026 that cap is $115.27 at the national rate, against $135.61 for a physician. Commercial and Medicaid rates aren’t set by that rule. Your contract or your state’s Medicaid program sets them, and they vary widely.
Start Here
There Is No Single “PMHNP Rate”
Psychiatric mental health nurse practitioners (PMHNPs) get paid by a mix of payers, and only one number in that mix is fixed by federal rule. It’s the Medicare limit for services billed under a nurse practitioner’s own National Provider Identifier (NPI). Commercial insurance and state Medicaid are set by contract or by state policy. They vary widely.
So outside Medicare, the real answer to “what do PMHNPs get reimbursed?” is a framework, not a dollar amount. Medicare’s 2026 amounts by code are in the table below. And what you keep depends as much on coding, denials and payer mix as it does on any fee schedule.
The Federal Rule
Medicare’s 85 Percent Of The Physician Fee Schedule
When a nurse practitioner bills Medicare Part B under their own NPI, the allowed amount tops out at 85 percent of the Medicare Physician Fee Schedule (PFS) amount for that service. The cap comes from federal regulation. It’s written into 42 CFR 414.56(c), which says that allowed amounts for the services of a nurse practitioner “may not exceed 85 percent of the physician fee schedule amount for the service.” See the eCFR text of 42 CFR 414.56 and CMS’s Advanced Practice Registered Nurses (APRNs) guidance for the current details.
Two details trip people up.
85% Is The Allowed Amount, Not Your Deposit
Medicare then generally pays 80 percent of that allowed amount. The beneficiary (or a secondary payer) owes the remaining 20 percent coinsurance. So the 85 percent sets the ceiling, and the 80/20 split decides who pays which share of it.
It Is Tied To The Physician Rate For The Same Code
The 85 percent is calculated against the physician fee schedule amount for the identical CPT code. If the underlying physician rate for a code changes in the annual fee schedule, the NP-billed amount moves with it.
2026 Medicare Amounts
PMHNP Medicare Rates By CPT Code (2026)
For the codes PMHNPs bill most, the 85 percent cap works out to the amounts below. The first dollar column is the 2026 Medicare Physician Fee Schedule national amount for an office (non-facility) setting. The second is 85 percent of it, the most Medicare allows when a PMHNP bills under their own NPI.
| CPT Code | What It Covers | Medicare National Amount | PMHNP Amount (85%) |
|---|---|---|---|
| 90791 | Psychiatric diagnostic evaluation, no medical services | $173.35 | $147.35 |
| 90792 | Psychiatric diagnostic evaluation with medical services | $202.08 | $171.77 |
| 90832 | Psychotherapy, 30 minutes | $85.84 | $72.96 |
| 90834 | Psychotherapy, 45 minutes | $113.90 | $96.82 |
| 90837 | Psychotherapy, 60 minutes | $167.00 | $141.95 |
| 90833 | Psychotherapy add-on with an E/M visit, 30 minutes | $81.50 | $69.28 |
| 90836 | Psychotherapy add-on with an E/M visit, 45 minutes | $103.21 | $87.73 |
| 90838 | Psychotherapy add-on with an E/M visit, 60 minutes | $136.61 | $116.12 |
| 99202 | New patient office visit, straightforward (15 min) | $75.15 | $63.88 |
| 99203 | New patient office visit, low complexity (30 min) | $117.57 | $99.93 |
| 99204 | New patient office visit, moderate complexity (45 min) | $177.36 | $150.76 |
| 99205 | New patient office visit, high complexity (60 min) | $236.81 | $201.29 |
| 99212 | Established patient office visit, straightforward (10 min) | $59.45 | $50.53 |
| 99213 | Established patient office visit, low complexity (20 min) | $95.19 | $80.91 |
| 99214 | Established patient office visit, moderate complexity (30 min) | $135.61 | $115.27 |
| 99215 | Established patient office visit, high complexity (40 min) | $192.39 | $163.53 |
In a facility setting such as a hospital, Medicare uses a lower facility amount for every code in this table.
Source: CMS Medicare Physician Fee Schedule data for calendar year 2026, the “Indicators for 2026” file in CMS’s PFS data catalog. Each national amount is the code’s total non-facility RVUs times the 2026 conversion factor of $33.4009, the factor for clinicians who aren’t qualifying APM participants (CMS CY 2026 final rule fact sheet). These are national amounts before Medicare’s locality adjustment (GPCI), so your MAC’s amount for your area will be higher or lower. The PMHNP column is 85 percent of each national amount, rounded to the cent. Checked October 4, 2026.
The Exception Everyone Asks About
Incident-To Billing And The 100 Percent Caveat
There’s one way a nurse practitioner’s service can be paid at 100 percent of the physician fee schedule instead of 85 percent, and it’s called “incident to” billing. The service is billed under a supervising physician’s NPI, and Medicare pays the full physician amount. The conditions are strict, though, and misusing incident-to is a well-known compliance risk.
Incident-to generally requires all of this. The physician established the plan of care and stays actively involved. For behavioral health services, Medicare allows general supervision, so the physician doesn’t have to be in the suite. And the patient isn’t new and doesn’t bring a new problem to that visit. The rules are technical and enforcement is real, so check the current requirements against CMS guidance and your Medicare Administrative Contractor before you rely on incident-to. Many practices bill under the NP’s own NPI at 85 percent on purpose, to keep billing clean and build the NP’s own claims history.
Incident-to is a Medicare billing construct. Commercial payers have their own rules about whether and how NP services can be billed under a physician, so don’t assume the Medicare framework carries over.
Quick Reference
Billing Scenario To Medicare Treatment
The table shows how Medicare treats common scenarios. It’s a simplification of complex rules, so check the specifics against current CMS guidance for your situation.
| Billing Scenario | Medicare Treatment |
|---|---|
| PMHNP bills Part B under their own NPI | Allowed amount capped at 85% of the physician fee schedule for that code (per 42 CFR 414.56). |
| Service qualifies and is billed “incident to” a supervising physician’s NPI | Paid at 100% of the physician fee schedule, but only if all incident-to conditions are met (established plan of care, supervision, not a new patient/problem). |
| New patient or a new problem addressed at the visit | Generally does not qualify for incident-to; bill under the NP’s own NPI at 85%. |
| Any Medicare-allowed service, after the allowed amount is set | Medicare pays roughly 80% of the allowed amount; patient or secondary payer covers the ~20% coinsurance. |
| Commercial (private) insurance | Not governed by the 85% rule. Rate is set by your contract with each payer and varies. Negotiate it. |
| State Medicaid | Set by each state’s Medicaid program; NP reimbursement policy and percentages vary by state. Check your state Medicaid manual. |
Commercial And Medicaid
Everything Outside Medicare Varies, So Read Your Contract
There’s no federal 85 percent rule for commercial insurers. Some plans pay NPs the same rate as physicians for the same code. Others apply a percentage reduction, and many negotiate rates individually with each practice. The only reliable way to know your commercial rate is to read your executed fee schedule with that payer. If a payer won’t share the fee schedule for the codes you bill most (for PMHNPs, usually the evaluation and management and psychotherapy add-on codes), treat that as something to negotiate, not a settled fact.
State Medicaid programs set their own NP reimbursement policy too. Some pay at parity with physicians and some pay a percentage, and supervision and enrollment rules differ from state to state. Your state Medicaid provider manual is the authority for your state. Don’t rely on figures quoted for a different state.
We don’t publish commercial or Medicaid dollar amounts or percentages here, and that’s on purpose. They change by payer, state, contract and year. A number that looks official but is wrong for your market can cost you real money. Medicare’s 85 percent rule is the one figure fixed by federal regulation. Every other rate varies. Verify it, then negotiate it.
What Moves The Number
Your Effective Rate Is About More Than The Fee Schedule
Two PMHNPs contracted at identical rates can collect very different amounts. The gap comes from the things that set your effective reimbursement, meaning the dollars that land in the practice per hour worked.
Payer Mix
The blend of Medicare, commercial, Medicaid, and self-pay in your panel shifts your blended rate more than any single contract. A panel weighted toward higher-paying commercial contracts collects more per visit than one weighted toward the lowest-paying Medicaid rates.
Coding Accuracy
Under-coding (billing a lower-level visit than your documentation supports) gives up revenue on every claim. Over-coding invites audits and paybacks. Few habits in a psychiatric practice pay off like picking the E/M level your documentation supports and using the psychotherapy add-on codes correctly.
Denials And Rework
A claim that’s denied, delayed or never resubmitted pays nothing, whatever the contracted rate. Your clean claim rate, timely filing and steady denial follow-up often matter more to take-home pay than a few points of rate.
Credentialing And Enrollment
You can’t bill a payer you aren’t enrolled and in-network with. A gap or lapse in credentialing turns visits into out-of-network or unbillable ones. Getting paneled with the right payers, and staying paneled, comes before any rate conversation.
No-Shows And Utilization
Empty slots collect nothing. Scheduling density, a workable no-show policy, and the mix of intake versus follow-up visits shape revenue per clinical hour independent of any fee schedule.
Contract Terms Beyond Rate
Timely-payment provisions, which codes are covered, prior-authorization burden, and clawback windows all affect what you keep. The headline rate is only one line of the contract.
Practical Steps
How To Improve What You Collect
You don’t control posted fee schedules, but you control a lot of your effective rate. In rough priority order:
1. Know Your Numbers
Pull your executed fee schedules and your top billed codes. You can’t negotiate or benchmark a rate you’ve never seen in writing.
2. Tighten Coding And Documentation
Make sure your documentation supports the level you bill, and that you aren’t routinely under-coding. That’s revenue you’re already entitled to.
3. Fix The Denial Leak
Track your denial reasons, resubmit within timely-filing windows, and eliminate the recurring, avoidable denials first.
4. Improve Payer Mix Deliberately
Where your license, ethics, and access goals allow, weight new-patient intake toward better-paying contracts and keep panels open with the payers that pay reliably.
5. Renegotiate On Evidence
Bring your volume, quality and access data to contract renewals. Payers do negotiate, and a documented ask lands better than a request with no data behind it.
6. Decide Your Billing Structure Intentionally
Whether you bill under your own NPI at 85% or use compliant incident-to (where appropriate) is a strategic choice with compliance and rate consequences. Decide it on purpose, not by default.
Common Questions
PMHNP Reimbursement FAQ
What Does Medicare Pay A PMHNP For 99214 With 90833?
At the 2026 national rates, Medicare allows $184.55 when a PMHNP bills 99214 with 90833 under their own NPI. That’s 85 percent of $135.61 for the visit ($115.27) plus 85 percent of $81.50 for the add-on ($69.28). A physician billing the same pair is allowed $217.11. Medicare pays 80 percent of the allowed amount, the patient or a secondary payer owes the other 20 percent, and your locality adjustment moves every number up or down.
Do Nurse Practitioners Get Paid Less Than Physicians By Medicare?
Yes, for services billed under the NP’s own NPI. The allowed amount is capped at 85 percent of the physician fee schedule for the same code, per 42 CFR 414.56. Under compliant incident-to billing, the same service billed under a supervising physician’s NPI can be paid at 100 percent of the physician rate.
Is The 85 Percent Rule The Same For Commercial Insurance?
No. The 85 percent figure is a Medicare rule. Commercial payers set NP rates by contract, and those rates vary. Some pay at parity with physicians; others apply a reduction. Read your fee schedule.
What Is Incident-To Billing, And Should I Use It?
Incident-to lets a qualifying NP service be billed under a supervising physician’s NPI at 100 percent of the physician rate. It only works when strict Medicare conditions are met (established plan of care, supervision, not a new patient or problem), and it carries audit risk if it’s misapplied. Many practices bill under the NP’s own NPI to keep billing clean. Check the current rules with CMS and your MAC before you rely on it.
How Does Medicaid Pay PMHNPs?
It depends on your state. Each state Medicaid program sets its own NP reimbursement policy and percentages. Your state Medicaid provider manual is the authoritative source; figures from another state may not apply.
Why Doesn’t This Page List Commercial Or Medicaid Dollar Amounts?
Because outside Medicare there’s no single correct number. Commercial and Medicaid rates vary by payer, state, contract and year. A specific figure that’s wrong for your market would mislead you and could cost you money. So for those payers we give you the framework and point you to the authoritative sources for your situation.
Collect What Your Contracts Already Pay
When two PMHNPs on the same fee schedule collect different amounts, the gap is usually under-coding and denials nobody worked. That’s the work behind our PMHNP billing services. Under Ongoing Billing we handle the claims, the denials and the A/R follow-up, so the contracted rate turns into a deposit. Pricing goes by practice size, from 7% of collections for a solo provider down to 4.5% at 26 to 50 providers. The monthly minimum is $300 for a solo practice. There’s no setup fee.
Informational only. This page is general education about billing and reimbursement, not legal, financial, tax, or coding advice. Rules and rates change; verify specifics with CMS, your Medicare Administrative Contractor, your payers, your state Medicaid program, and a qualified professional before acting. Last reviewed: July 2026.