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See a sample rate comparisonCPT 99245 Fee Schedule
Last Verified: October 2026
Healthcare providers use this code to document and receive reimbursement for visits that address high-level medical decision-making, often including multiple diagnoses or prescription management.
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
| 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 | High |
| Medicare Fee Schedule | View Medicare rates for 99245 |
| Medicaid Fee Schedule | View Medicaid rates for 99245 |
National average reimbursement for CPT 99245 by major payers:
$103.20
$238.97
$250.03
$229.04
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CPT 99245
5 of 25 sample ratesHigher to lower in this preview
Steffanie Campbell
Kelsey-Seybold Medical Group PLLC
$691.08Published rateMichael Nguyen
$316.17Published rateNacogdoches Cardiovascular Associates PA
Nacogdoches Cardiovascular Associates, PA
$259.77Published rateAustin Williams
Austin Oscar Williams Md PA
$183.91Published rateThomas Vinson
Round Rock Cardiology
$157.35Published rate
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See a sample payer proposalCPT 99245 vs. Other Consultations Codes
The CPT 99245 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 99245 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 99245. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99245 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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