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See a sample rate comparisonCPT 99221 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
1st Hosp Ip Obs Sf Low 40, Initial Hospital Inpatient Or Observation Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Or Low Level Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 40 Minutes Must Be Met Or Exceeded
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Hospital Inpatient and Observation Care Services |
| Common Place of Service | 21 - Inpatient Hospital 22 - On Campus Outpatient Hospital 51 - Inpatient Psychiatric Facility |
| Common Modifiers | 25 - Significant, separately identifiable E/M service same day GC - Service performed by resident under supervision |
| Complexity Level | Low |
| ASAM Level | Level 4 - Medically Managed Inpatient |
| Care Type | Treatment |
| Setting | Inpatient |
| Medicare Fee Schedule | $74.48 national non-facility rate (2026) · View Medicare rates for 99221 |
| Medicaid Fee Schedule | $60.47 median of the 8 states in the free preview · View Medicaid rates for 99221 |
National average reimbursement for CPT 99221 by major payers:
$109.43
$86.74
$123.42
$138.06
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CPT 99221
5 of 25 sample ratesHigher to lower in this preview
Nolan Kinne
Faculty Physicians And Surgeons Of Llusm
$252.41Published rateRobert Rubino
Atlantic Health System Inc
$196.74Published rateSoma Mandal
Summit Medical Group, P.A.
$143.25Published rateMian Hasan
Vanguard Medical Group, LLC D/B/A Florida Heart Specialists
$97.05Published rateNatalia Miranda
$62.15Published rate
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See a sample payer proposalCPT 99221 vs. Other Hospital Inpatient and Observation Care Services Codes
The CPT 99221 code is part of the Evaluation and Management services used for Hospital Inpatient and Observation Care Services. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 99221 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 99221-CPT | Low | 1st Hosp Ip Obs Sf Low 40, Initial Hospital Inpatient Or Observation Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Or Low Level Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 40 Minutes Must Be Met Or Exceeded |
| 99222-CPT | Moderate | 1st Hosp Ip Obs Moderate 55, Initial Hospital Inpatient Or Observation Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And Or Examination And Moderate Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 55 Minutes Must Be Met Or Exceeded |
| 99223-CPT | High | 1st Hosp Ip Obs High 75, Initial Hospital Inpatient Or Observation Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And Or Examination And High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 75 Minutes Must Be Met Or Exceeded |
| 99231-CPT | Low | Sbsq Hosp Ip Obs Sf Low 25, Subsequent Hospital Inpatient Or Observation Care Per Day For The Evaluation And Management Of A Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Or Low Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 25 Minutes Must Be Met Or Exceeded |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99221. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99221 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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Frequently Asked Questions
The CPT 99221 code is part of the Evaluation and Management services specifically used for Hospital Inpatient and Observation Care Services. It denotes a moderate-complexity encounter, demanding more provider time and moderate medical decision-making compared to lower-level E/M codes. This code typically applies to situations involving multiple diagnoses, medication management, or the interpretation of various tests, leading to higher reimbursement and more detailed documentation requirements. It is distinct from CPT codes such as 99222, which also represents moderate complexity but requires more time and higher medical decision-making, and 99223, which signifies a high-complexity encounter demanding the most time and highest level of medical decision-making. For specific details regarding reimbursement rates based on location or other specific situations, you can utilize Payerprice's fee schedule lookup tool by searching with the CPT code and your specific location.