CPT 99243 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 • 19 - Off Campus Outpatient Hospital |
| Common Modifiers | • None • 25 - Significant, separately identifiable E/M service same day • 95 - Telemedicine - audio and video |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 99243 |
National average reimbursement for CPT 99243 by major payers:
$55.25
$133.20
$139.97
$136.45
| 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 99243 | ||||||
United | 99243 | $136.00 | 1578671392 - MARCY LIM | 760221050 | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99243 | $113.36 | 1194179010 - ARAMIS COSME | 861401273 - (TX) HIGH QUALITY MEDICAL SERVICES PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $142.05 | 1821032731 - GEORGE JENKINS | 262126265 - (TX) ASSOCIATES IN SURGICAL ACUTE CARE | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99243 | $113.36 | 1396740239 - PRADIP MORBIA | 760403085 - (TX) GULF COAST CARDIOLOGY GROUP, PLLC | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99243 | $161.33 | 1285871681 - VANDANA SHAH | 823426999 | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $142.05 | 1881033025 - CARDIAC CLINIC OF TEXAS | 463016014 - (TX) CARDIAC CLINIC OF TEXAS | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99243 | $255.75 | 1619436474 - JACOB SAMBURSKY | 931272735 | TX | Neurology Physician (2084N0400X) |
United | 99243 | $114.36 | 1912998618 - HANH TRUONG | 760673289 | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $121.98 | 1255575049 - REMY TEQWIMUAH | 202798379 - (TX) CLEAR LAKE SPECIALTIES, PA | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $138.55 | 1366548547 - SUSHANTA GOSWAMI | 842068606 - (TX) HNI PHYSICIAN SERVICES OF TEXAS INC | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $176.55 | 1457358103 - BELLVILLE HOSPITAL DISTRICT, BELLVILLE GENERAL HOSPITAL | 274005511 - BELLVILLE MEDICAL CENTER | TX | General Acute Care Hospital (282N00000X) |
United | 99243 | $113.36 | 1366016719 - MORGAN LAMPSON | 311756818 - (TX) ASIAN AMERICAN HEALTH COALITION OF THE GREATER HOUSTON AREA | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $132.25 | 1912388141 - DIPALI PATEL | 872146287 | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $187.38 | 1154796019 - SALIMA ALI | 742109824 - (TX) AUSTIN REGIONAL CLINIC PA | TX | Internal Medicine Physician (207R00000X) |
United | 99243 | $166.25 | 1699832873 - CARL EARNEST | 752616977 - CHRISTUS TRINITY CLINIC | 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 99243 vs. Other Consultations Codes
The CPT 99243 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 99243 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 99243. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99243 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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