Medicare Reimbursement by Provider Type: LCSW, NP, PA (2026)

Medicare reimbursement depends on who bills the service, not only on the code. Medicare pays clinical social workers, marriage and family therapists and mental health counselors 75% of the fee schedule amount; nurse practitioners, physician assistants and clinical nurse specialists 85%; and clinical psychologists, physicians and certified nurse-midwives 100% (42 CFR 414.53, 414.52, 414.56, 414.62, 414.20 and 414.54).

Pick a code and the clinician whose NPI goes on the claim. The tool applies that percentage to the fee schedule amount for your ZIP, setting and date, compares every provider type, and says plainly when one can't bill the code.

Medicare reimbursement by provider type: the percentages

Every percentage is a share of the same number: the physician fee schedule amount for the code, locality, setting and date.

The 75% for social workers, MFTs and counselors is written as 75% of what a clinical psychologist is paid. Psychologists are paid 100% of the fee schedule, so the result is 75% of the fee schedule amount.

Sources: eCFR, 42 CFR §§414.20, 414.48, 414.52, 414.53, 414.54, 414.56, 414.62, 414.64; CMS Pub. 100-04, ch. 12 (Rev. 13753), ch. 5 and ch. 4 §300.4; CMS MLN1986542, Medicare & Mental Health Coverage (March 2026). Verified October 6, 2026.

Who can bill what

A percentage only matters if the provider type can bill the code. Three limits catch most practices:

• No E/M for behavioral health clinicians. CMS says clinical psychologists, clinical social workers, MFTs and mental health counselors "cannot independently bill Medicare for E/M visits" (CY 2025 final rule, 89 FR 97929). That rules out office visits such as 99214, the diagnostic evaluation with medical services (90792), and the psychotherapy add-ons that report alongside an E/M visit (90833, 90836, 90838). The tool marks these "not billable by this provider type" instead of showing 75% of an E/M amount.
• Testing is for psychologists and medical practitioners. CMS's mental health booklet lists physicians, psychologists, NPs, CNSs, PAs and nurse-midwives for psychological and neuropsychological testing such as 96130. It doesn't list social workers, MFTs or counselors, so the tool doesn't price testing for them.
• Medical nutrition therapy is for dietitians only. "Only a registered dietitian or nutrition professional may provide the services" (42 CFR 410.134). Physicians and NPs get no amount for 97802.

Setting matters too. Social workers, MFTs, counselors and dietitians aren't paid under their own benefit for hospital inpatients (social workers and dietitians also not for SNF inpatients), so the tool prints that exclusion beside the facility amount. Therapists in private practice have no facility amount: Medicare doesn't pay them for hospital patients.

For the full list of mental health codes and how they differ, see psychotherapy billing codes.

What the amount means

The number the tool shows is the allowed amount for that provider type: the total Medicare recognizes for the service, before it is split between Medicare and the patient.

• It includes the patient's 20% coinsurance. Medicare pays 80% of it once the deductible is met.
• It isn't the remittance. Medicare's payment is lower than the allowed amount, and the 2% sequestration reduction comes off that payment. Neither is applied here.
• It isn't a guarantee. A priced code doesn't mean the service is covered for a given patient, or that the clinician is enrolled with Medicare or eligible to bill it.

Credentials map to Medicare categories, but the map isn't enrollment. An LPC, LMHC or LCPC bills as a mental health counselor only after meeting Medicare's requirements and enrolling; the same goes for every other row.

Worked example: 90837 for each provider type

Here is the current national amount for 90837, the hour-long psychotherapy code. Switch to facility or enter a ZIP to see your locality.

That is what a clinical psychologist bills against, and the 100% row for physicians. From there:

• An LCSW, LMFT or LPC billing under their own NPI is allowed 75% of the 90837 amount shown above.
• A psychiatric NP or PA is allowed 85% of it.
• A non-participating psychiatrist is allowed 95% of it, and can charge the patient up to 115% of that 95% figure when not accepting assignment.

Now change the code to 99214 in the tool. The NP row shows 85% of the office visit amount; the social worker, MFT, counselor and psychologist rows show "not billable", because none of them can bill E/M. Change it to 90834 and every behavioral health row is priced again.

Therapy assistants: CQ and CO

PTA and OTA services aren't a separate provider type with a lower allowed amount. When a service is furnished in whole or in part by an assistant, the claim carries CQ (PT) or CO (OT), the allowed amount stays the same, and Medicare cuts its own payment by 15%. CMS says the reduction "is taken from the paid amount, i.e., the actual amount paid not the MPFS allowed amount," after the multiple procedure reduction and coinsurance and right before sequestration.

CMS's own illustrative example in Transmittal R11129CP: an allowed amount of $100, coinsurance of $20, leaving $80; the 15% assistant reduction takes $12, leaving $68 before sequestration. The patient's coinsurance is still 20% of the full $100.

For a whole visit with several timed codes, the therapy MPPR calculator applies the 50% practice expense reduction. Therapy codes also need the GP modifier or GO/GN for the plan of care.

Sources: 42 CFR 410.59(a)(4), 410.60(a)(4); CMS Pub. 100-04, ch. 5 §§10, 20; Transmittal R11129CP (CR 12397, November 22, 2021). Verified October 6, 2026.

Incident-to billing is a different calculation

When a social worker or NP furnishes a service as auxiliary personnel and the claim goes out under a physician's NPI, the physician rate applies; under an NP or PA's NPI, 85%. Whether a service qualifies depends on supervision, setting and who started the plan of care, which a code and ZIP can't tell us. Social workers, MFTs and counselors can't have services billed incident to themselves, and medical nutrition therapy can't be billed incident to anyone.

So the tool answers one question only: what Medicare allows when the clinician bills under their own NPI. For the supervision rules, read incident-to billing.

Non-participating physicians

Participation is a status, not a provider type, so it sits in the tool as its own row. A non-participating physician's allowed amount is 95% of the participating amount (42 CFR 414.20(b)). When the physician doesn't accept assignment, they may charge the patient up to the limiting charge, 115% of that non-participating amount (42 CFR 414.48(b)). The limiting charge is a ceiling on the bill, not an allowed amount.

Combinations the tool won't price

Rather than fall back to the physician amount, the tool says why it has no answer:

Need a sheet for your provider mix and contracts?

A group with a psychologist, two LCSWs and a psychiatric NP needs one code list priced several ways at its own locality, next to what each commercial contract pays. Send us the codes you bill and who bills them, and we'll put the sheet together with you; see fee sheets. For a free starting list, use the behavioral health fee schedule.