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See a sample rate comparisonCPT 99231 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.
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
| 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 | GC - Service performed by resident under supervision 25 - Significant, separately identifiable E/M service same day |
| Complexity Level | Low |
| ASAM Level | Level 4 - Medically Managed Inpatient |
| Care Type | Treatment |
| Setting | Inpatient |
| Medicare Fee Schedule | $44.09 national non-facility rate (2026) · View Medicare rates for 99231 |
| Medicaid Fee Schedule | $35.605 median of the 8 states in the free preview · View Medicaid rates for 99231 |
National average reimbursement for CPT 99231 by major payers:
$54.09
$48.81
$66.26
$66.52
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CPT 99231
5 of 25 sample ratesHigher to lower in this preview
Helen Kao
$226.00Published rateRoxan Saidi
Caremount Medical, P.C.
$105.86Published rateJoseph Cano
Texas Digestive Disease Consultants
$51.15Published rateLily Yee
Thomas Lyo Medical PC
$39.18Published rateJan Shim
$26.94Published rate
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See a sample payer proposalCPT 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-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 |
| 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 |
| 99232-CPT | Moderate | Sbsq Hosp Ip Obs Moderate 35, 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 Moderate Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 35 Minutes Must Be Met Or Exceeded |
| 99233-CPT | High | Sbsq Hosp Ip Obs High 50, 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 High Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 50 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 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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Frequently Asked Questions
CPT stands for Current Procedural Terminology. CPT codes are standardized five-digit alphanumeric codes used by healthcare professionals to report medical, surgical, and diagnostic services and procedures to entities such as physicians, health insurance companies, and accreditation organizations. They ensure uniformity in medical billing and documentation.
Finding the exact cost of a medical procedure can be complex due to varying factors like your insurance plan, location, and healthcare provider. For specific cost information based on a CPT code and your location, you can use tools like Payerprice's fee schedule lookup tool. It allows you to search for pricing information for specific services to help you understand potential costs.
Several factors influence healthcare costs, including the type of service, geographic location, the specific healthcare provider or facility (e.g., hospital vs. outpatient clinic), your insurance coverage and deductible, the complexity of the procedure, and negotiated rates between providers and insurance companies. These elements can cause significant price variations for the same service.
Price variations occur due to several reasons: lack of standardized pricing across different providers and regions, varying negotiated rates with different insurance plans, differences in facility overhead (hospitals often have higher costs than standalone clinics), the specific equipment used, and regional market competition. This lack of transparency can make it difficult for consumers to compare costs effectively.
Payerprice is a platform designed to help users understand healthcare costs. It offers tools, such as a fee schedule lookup, that allow individuals to search for pricing information for medical procedures using CPT codes and specific locations. This can help you compare costs, plan for medical expenses, and make more informed decisions about your healthcare.
Payerprice's fee schedule lookup tool can provide valuable insights into the expected costs of medical procedures based on CPT codes and specific locations. While it helps you understand the general pricing, your actual out-of-pocket cost will also depend on your specific insurance plan details, including your deductible, co-insurance, and any out-of-pocket maximums. It's always best to verify with your insurance provider for your precise personal cost.