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See a sample rate comparisonCPT 99242 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.
Off Op Consltj New Est Sf 20, Office Or Other Outpatient Consultation For A New Or Established Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 20 Minutes Must Be Met Or Exceeded
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Consultations |
| Common Place of Service | 11 - Office 22 - On Campus Outpatient Hospital 20 - Urgent Care Facility |
| Common Modifiers | None 25 - Significant, separately identifiable E/M service same day GQ - Alaska and Hawaii only - asynchronous telecommunication system |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 99242 |
| Medicaid Fee Schedule | View Medicaid rates for 99242 |
National average reimbursement for CPT 99242 by major payers:
$36.86
$93.65
$118.19
$83.55
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CPT 99242
5 of 25 sample ratesHigher to lower in this preview
Jessica Wang
$464.20Published rateScott Mckinstry
$136.00Published rateTaylor Infante
El Paso County Hospital District
$109.77Published rateSatish Dinakar
Satish Dinakar Md PLLC
$77.11Published rateOrfaly Medical Professional Corporation, Broadway Elite Medical
Orfaly Medical Professional Corporation
$68.04Published rate
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See a sample payer proposalCPT 99242 vs. Other Consultations Codes
The CPT 99242 code is part of the Evaluation and Management services used for Consultations. 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 99242 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 |
|---|---|---|
| 99242-CPT | Low | Off Op Consltj New Est Sf 20, Office Or Other Outpatient Consultation For A New Or Established Patient Which Requires A Medically Appropriate History And Or Examination And Straightforward Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 20 Minutes Must Be Met Or Exceeded |
| 99243-CPT | Low | Off Op Cnsltj New Est Low 30, Office Or Other Outpatient Consultation For A New Or Established Patient Which Requires A Medically Appropriate History And Or Examination And Low Level Of Medical Decision Making When Using Total Time On The Date Of The Encounter For Code Selection 30 Minutes Must Be Met Or Exceeded |
| 99244-CPT | Moderate | Off Op Cnsltj New Est Mod 40, Office Or Other Outpatient Consultation For A New Or Established 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 40 Minutes Must Be Met Or Exceeded |
| 99245-CPT | High | Off Op Consltj New Est Hi 55, Office Or Other Outpatient Consultation For A New Or Established 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 55 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 99242. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99242 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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