CPT 99231 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | • Evaluation and Management • Hospital Inpatient and Observation Care Services |
| Common Place of Service | • 21 - Inpatient Hospital • 51 - Inpatient Psychiatric Facility • 22 - On Campus-Outpatient Hospital |
| Common Modifiers | • None • GC - Service has been performed in part by a resident under the direction of a teaching physician • 25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service |
| Complexity Level | Moderate |
National average reimbursement for CPT 99231 by major payers:
$54.09
$48.81
$66.26
$66.79
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 99231 | ||||||
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CPT 99231 vs. Other Hospital Inpatient and Observation Care Services Codes
The CPT 99231 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 99231 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 | Low | 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. (Desc Rvsd 1/1/23) |
| 99222 | Moderate | 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. (Desc Rvsd 1/1/23) |
| 99223 | High | 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. (Desc Rvsd 1/1/23) |
| 99231 | Low | 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. (Desc Rvsd 1/1/23) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99231. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99231 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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