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NPI 1992758411 · Hurricane, WV · Internal Medicine Physician
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James Toothman is a internal medicine physician provider located in Hurricane, West Virginia. This profile covers 8 Medicare and 2 Medicaid CPT/HCPCS procedure codes, with claims volume, average reimbursement, and total revenue by code, benchmarked against other providers billing the same services.
Provider details (source: NPPES NPI Registry)
| Field | Value |
|---|---|
| Entity Type | Individual |
| Organization | James Toothman |
| Address | 13 Edgewood Dr |
| City | Hurricane |
| State | WV |
| ZIP | 25526 |
| Taxonomy | Internal Medicine Physician |
| NPI Enumerated | May 18, 2006 |
| NPI Deactivated | January 12, 2024 |
Lifetime revenue by payer source (source: CMS Medicare & Medicaid claims data)
| Payer Source | Total Paid |
|---|---|
| Medicare | $528.3K |
| Medicaid | $19.8K |
This provider is effectively Medicare-driven: lifetime Medicare revenue is $528.3K compared with $19.8K in Medicaid, so Medicare accounts for the vast majority of billed revenue and the practice appears commercially focused on Medicare beneficiaries rather than Medicaid populations. The small absolute Medicaid total ($19.8K) indicates Medicaid is a minor component of this provider’s payer mix and operational footprint.
Medicare revenue is highly concentrated: the precomputed top-three Medicare codes account for 81.6% of the provider's total Medicare revenue. In particular, 99309 alone represents 63.0% of Medicare revenue ($334K), followed by 99305 at 11.1% ($59.1K) and G0439 at 7.4% ($39.2K), which signals dependence on a narrow set of services for most Medicare income.
The code mix points to a service model centered on nursing facility and site-of-service visits plus preventive care: high-volume nursing facility E/M codes (99309, 99305, 99349, 99316) dominate revenue, while annual wellness visits (G0438/G0439) and advance care planning (99497) are also material. For example, Medicare shows 4.3K claims for 99309 and 372 claims for 99349 (home/residence visits) totaling $35K, consistent with a practice that delivers long-term care and in-residence services along with AWVs.
National competitive standing for the provider’s top Medicare codes is unusually strong: 99309 ranks #106 of 28092 providers nationally (100th percentile; extreme outlier), indicating an outsized national volume for subsequent nursing facility care visits. Complementary codes also show elevated presence—99305 ranks #141 of 10126 (99th percentile; notably above typical), and G0439 ranks #3406 of 105855 (97th percentile; notably above typical)—together these ranks characterize the provider as a major national participant for nursing facility E/M and AWV activity.
By contrast, the provider’s Medicaid footprint is small but extremely concentrated: the precomputed top-three Medicaid codes account for 100.0% of Medicaid revenue, with 99309 contributing 92.8% ($18.2K; 478 claims) and 99308 making up the remaining 7.2% ($1.4K; 52 claims). In-state ranks for those Medicaid codes are unremarkable—99309 at #34 of 78 (57th percentile; typical) and 99308 at #74 of 93 (21st percentile; typical)—so the provider is not a dominant Medicaid performer in-state despite high Medicaid concentration in a couple of codes.
There is a meaningful payer-level payment gap on identical services: Medicare average paid/claim for 99309 is $77 while Medicaid average paid/claim for the same code is $38, reflecting substantially higher Medicare reimbursement per encounter for nursing facility subsequent visits. This spread suggests the provider’s revenue mix benefits from Medicare’s higher unit payment on its core nursing facility services.
The provider’s longevity is notable: NPI enumerated 2006-05-18 (~20 years ago), indicating a long-standing presence in the market that aligns with the sustained high volumes reported for nursing facility and related services. Tenure coupled with concentrated code dominance in Medicare suggests established referral or contractual relationships with post-acute and long-term care settings.
From an analytic and operational perspective, the provider’s revenue is highly sensitive to utilization or policy changes affecting nursing facility E/M and AWV codes given that the top three Medicare codes account for 81.6% of Medicare revenue and the top three Medicaid codes account for 100.0% of Medicaid revenue. Ongoing monitoring of utilization trends, payer edits, and payment policy for 99309/99305 and AWV codes would be prudent for payer/provider analysts assessing financial and utilization risk.
Medicare revenue breakdown by CPT/HCPCS procedure code.
View: Bar Chart1 / 2
The CPT/HCPCS codes generating the most Medicare revenue for this provider.
8 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| 99309 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a moderate level of medical decision making or the provider… | 4,340 | $80 | $334K |
| 99305 | The provider sees a patient for an initial nursing facility care visit involving evaluation and management (E/M). The visit involves moderate medical decision making or the provider spends at least… | 600 | $100 | $59.1K |
| G0439 | Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit | 320 | $120 | $39.2K |
| 99349 | The provider sees an established patient for a home or residence visit involving evaluation and management (E/M). The visit involves moderate medical decision making or the provider spends at least… | 370 | $90 | $35K |
| G0438 | Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit | 190 | $160 | $29.5K |
| 99497 | The provider discusses and shares planning with a patient, his family, or an individual representing the patient, regarding the future health care needs of the patient. Use this code for the first 30… | 310 | $60 | $18.7K |
| 99316 | The provider sees a patient for nursing facility discharge management requiring more than 30 minutes. | 140 | $100 | $13.4K |
| 99308 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a low level of medical decision making and/or the provider… | 30 | $50 | $1.3K |
How this provider's Medicare billing volume and revenue compare to other providers nationally and within its state, across 8 CPT/HCPCS codes.
Medicaid revenue breakdown by year and by CPT/HCPCS procedure code, including monthly billing trends and the top codes driving revenue.
View: By Year1 / 3
Every CPT/HCPCS code this provider has billed to Medicaid, with claims volume, average payment, and total revenue.
2 rows
| CPT/HCPCS Code | Description | Claims | Avg Paid | Revenue |
|---|---|---|---|---|
| 99309 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a moderate level of medical decision making or the provider… | 480 | $40 | $18.2K |
| 99308 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a low level of medical decision making and/or the provider… | 50 | $30 | $1.4K |
How this provider's Medicaid billing volume and revenue compare to other West Virginia providers billing the same CPT/HCPCS codes.
Full comparison — all codes billed, vs. West Virginia median
2 rows
| CPT/HCPCS Code | Description | Rank | Provider Count | Median Claims | Avg Paid | Average Revenue |
|---|---|---|---|---|---|---|
| 99309 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a moderate level of medical decision making or the provider… | 34 | 80 | 310 | $10 | $37.1K |
| 99308 | The provider sees a patient for a subsequent nursing facility care visit involving evaluation and management (E/M). The visit involves a low level of medical decision making and/or the provider… | 74 | 90 | 370 | $10 | $15.9K |
Other providers in the same ZIP code as James Toothman, ranked by combined Medicare and Medicaid revenue.
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