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 | Moderate |
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 | $125.44 | 1750969028 - AMULYA SAJJA | 204923281 - MEMORIAL HERMANN MEDICAL GROUP | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $64.41 | 1528047115 - DILAWAR AJANI | 465251414 - (TX) KATY FAMILY PHYSICIANS PA | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $146.16 | 1184733925 - TARA MYERS | 202044998 - (TX) CYPRESS EMERGENCY ASSOCIATES, PA | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $78.23 | 1003134974 - RUBY SHAH | 811111364 - (TX) VITALITY WEIGHT LOSS AND WELLNESS INSTITUTE PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $110.62 | 1578671392 - MARCY LIM | 760565432 - CARDIOVASCULAR ASSOCIATION PLLC | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $136.00 | 1962582379 - ARUNIMA MISRA | 760221050 | TX | Cardiovascular Disease Physician (207RC0000X) |
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 | $74.88 | 1679768378 - RICHARD STEEL | 273830550 | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $136.00 | 1740281302 - SCOTT MCKINSTRY | 760221050 | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $103.76 | 1336393693 - JOHN M STURGEON MD, P.A. | 263696675 - (TX) JOHN M STURGEON MD PA | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $96.62 | 1922194992 - ASIF AZIZ | 873827578 | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $73.62 | 1255632873 - DAVID TURBAY, MD, PLLC | 273944843 - (TX) DAVID TURBAY MD PLLC 401K PLAN | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99242 | $139.05 | 1114371937 - SHAWN GURWARA | 300520570 - (TX) METHODIST HOSPITAL | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $92.05 | 1144277542 - RICHARDSON PHYSICIAN ALLIANCE | 752896138 - MEDHEALTH | TX | Internal Medicine Physician (207R00000X) |
United | 99242 | $77.77 | 1972794154 - MELISSA AMADOR | 922465140 | 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 | 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 | 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 | 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 | 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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