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Home/Resources/Reimbursement Calculator
Tool

Run the math on what
your pharmacy could capture.

Drop in your store count and weekly clinical encounter volume. Adjust the service mix and payer mix to match your reality. Get a defensible per-code annual reimbursement estimate at your current capture rate versus what is possible with full documentation.

Your pharmacy

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Service mix

Drag any slider — the mix rebalances to 100%.

Chronic Care Management (CCM)28%
Medication Therapy Management (MTM)22%
Point-of-care testing (POCT)18%
Immunizations24%
Tobacco cessation counseling8%

Payer mix

Roughly how your clinical patients break down.

Medicare Part B48%
Commercial and employer plans34%
Medicaid18%
Your annual opportunity
$647,000

At full documentation across 6 stores — about $107,800 per store, on 13,104 billable encounters a year.

Full documentation$53,900 / mo
Billing today (about 25%)$13,500 / mo
Left on the table$40,400 / mo
$485,000 in clinical revenue goes unbilled over the next 12 months at your current capture rate.
Book a demo → 20 minutes. We pressure-test these numbers against your real encounter volume — no deck, just the math.

Where the number comes from

99490CCM, first 20 min per patient-month$223,700
99439CCM add-on 20 min — 40% of months$67,800
99605MTM, initial 15 min — 40% of sessions$79,400
99606MTM follow-up — 60% of sessions$59,500
87880Rapid strep test$19,700
87804Rapid influenza test$19,700
99202Test-and-treat assessment — 40% of tests$69,600
90471Immunization admin, first vaccine$80,400
90472Admin, each added vaccine — 25% of visits$11,600
99406Tobacco cessation, 3–10 min$15,500
About this estimate. Figures are modeled from CMS 2026 Medicare Physician Fee Schedule national averages and adjusted by your stated payer mix. Actual reimbursement varies by MAC region, locality adjustment, individual payer contracts, and incident-to billing posture. RHC and FQHC pharmacies bill many of these codes through different mechanisms (G0511, G0512). This calculator is a planning tool, not a guarantee, your real number depends on documentation discipline, denial-management practice, and the contracts you hold.
What Changes The Number

Three levers move this estimate
by 30% or more.

The math above assumes documentation discipline, an incident-to posture, and a denial-management practice. The pharmacies that hit it have a clear playbook on each of three levers, and the gap between average and best-in-class is wider than most operators realize.

1

Documentation discipline

Time-tracked CCM in MedMe captures 40 to 60% more billable minutes than retroactive notes. The difference between 99490 and 99491 plus add-ons is documentation, not effort.

2

Incident-to billing posture

Pharmacies billing under a supervising physician through incident-to or general supervision rules typically capture 2 to 3 times more services. RHTP and provider-status changes are widening this lever in 2026.

3

Denial management

Industry-average pharmacy clinical-service denial rates run 18 to 24%. MedMe customers bring that under 6% by surfacing denials in real time and pre-flagging documentation gaps before submission.

Talk To Our Team

See your real number
on a 20-minute call.

Send us a week of your encounter volume. We will back-of-envelope your annual reimbursement and walk through the codes that move the needle for your service mix.

Book a demo →