CPT 99242 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 • 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 |
National average reimbursement for CPT 99242 by major payers:
$36.86
$93.65
$118.19
$98.74
| 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 99242 | ||||||
United | 99242 | $69.01 | 1639260920 - ALBERT BRADEN | 741322777 - (TX) WEST UNIVERSITY INTERNAL MEDICINE, PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $68.04 | 1013573948 - ORFALY MEDICAL PROFESSIONAL CORPORATION, BROADWAY ELITE MEDICAL | 263918056 - (TX) ORFALY MEDICAL PROFESSIONAL CORPORATION | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $94.73 | 1255301834 - CESAR CALIANGA | 741842169 - (TX) CENTRO DE SALUD FAMILIAR LA FE INC | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $109.77 | 1932691441 - TAYLOR INFANTE | 746000756 - (TX) EL PASO COUNTY HOSPITAL DISTRICT | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $126.44 | 1487815544 - ELLEN FREMION | 300791563 | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $82.83 | 1194300376 - SERVE ALL MEDICAL ROUND ROCK, PLLC, CLINICA HISPANA | 862011266 - (TX) SERVE ALL MEDICAL ROUND ROCK PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $227.50 | 1730610965 - JENNY RIECKE | 756002868 | TX | Neurology Physician (2084N0400X) |
United | 99242 | $73.62 | 1508136052 - FEDERICO MAESE MD PA, FERRIS HEART CENTER | 752723791 - (TX) FEDERICO MAESE MD PA | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $136.00 | 1740281302 - SCOTT MCKINSTRY | 760221050 | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $110.62 | 1578671392 - MARCY LIM | 760565432 - CARDIOVASCULAR ASSOCIATION PLLC | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $96.66 | 1306987474 - MUSTAFA MOAZAM | 274687405 - (CO) MOAZAM PA | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $136.00 | 1538146022 - ARUP ACHARI | 760221050 | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $82.83 | 1790715035 - MICHAEL SIROPAIDES | 273401164 - (TX) RAJIV AGARWAL MD PA | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $98.36 | 1780979823 - ALOK DESH | 462718719 - ACCESS TELECARE PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $139.14 | 1922673656 - BARIS VEFALI | 863083267 - (TX) AUSTIN CARDIOLOGY CLINIC PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 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 | 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. (Desc Rvsd 1/1/23) |
| 99243-CPT | Low | 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. (Desc Rvsd 1/1/23) |
| 99244-CPT | Moderate | 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. (Desc Rvsd 1/1/23) |
| 99245-CPT | High | 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. (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 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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