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See a sample rate comparisonCPT 99252 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.
Ip Obs Consltj New Est Sf 35, Inpatient Or Observation 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 35 Minutes Must Be Met Or Exceeded
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Consultations |
| Common Place of Service | 21 - Inpatient Hospital 22 - On Campus Outpatient Hospital 99 - Other POS |
| Common Modifiers | 25 - Significant, separately identifiable E/M service same day GC - Service performed by resident under supervision |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 99252 |
| Medicaid Fee Schedule | $60.33 median of the 7 states in the free preview · View Medicaid rates for 99252 |
National average reimbursement for CPT 99252 by major payers:
$42.93
$71.80
$124.00
$83.44
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CPT 99252
5 of 25 sample ratesHigher to lower in this preview
Harriet Adeleke
Kelsey-Seybold Medical Group PLLC
$173.69Published rateMatthew Lenz
Medical Clinic Of Houston, LLP
$115.30Published rateBrian Joe
Brian Joe Md PA
$89.15Published rateFelix Rivera
$68.76Published rateMonzer H Yazji Md & Associates PLLC, Asas Health
$55.38Published rate
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Payer Contract Negotiation
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See a sample payer proposalCPT 99252 vs. Other Consultations Codes
The CPT 99252 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 99252 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 |
|---|---|---|
| 99252-CPT | Low | Ip Obs Consltj New Est Sf 35, Inpatient Or Observation 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 35 Minutes Must Be Met Or Exceeded |
| 99253-CPT | Low | Ip Obs Cnsltj New Est Low 45, Inpatient Or Observation 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 45 Minutes Must Be Met Or Exceeded |
| 99254-CPT | Moderate | Ip Obs Cnsltj New Est Mod 60, Inpatient Or Observation 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 60 Minutes Must Be Met Or Exceeded |
| 99255-CPT | High | Ip Obs Consltj New Est Hi 80, Inpatient Or Observation 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 80 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 99252. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99252 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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Frequently Asked Questions
A CPT (Current Procedural Terminology) code is a five-digit numerical code used by healthcare providers to describe medical, surgical, and diagnostic services. They are crucial for consistent communication between healthcare providers, insurance companies, and government agencies, enabling accurate billing, claim processing, and data analysis.
To find the estimated cost of a specific medical procedure, especially tailored to your individual situation and location, you can utilize a specialized tool. Payerprice offers a fee schedule lookup tool that allows users to search with a CPT code and specific location to get detailed pricing information relevant to their needs. This can help you understand potential costs before receiving care.
A fee schedule is a comprehensive listing of fees used by insurance companies or government programs (like Medicare or Medicaid) to pay doctors or other providers for specific medical services or procedures. It sets the maximum allowable amount that the payer will reimburse for each service. Providers may also have their own internal fee schedules for their billed charges.
Healthcare costs can vary significantly for the same service due to several factors, including: Provider differences: Hospitals, clinics, and individual practitioners have different overheads and negotiation powers with insurers. Location: Costs can vary by city, state, and even within different neighborhoods of the same city. Insurance plans: Your insurance plan's negotiated rates with providers will affect your out-of-pocket costs. Facility type: Outpatient clinics generally cost less than hospital-based outpatient departments for the same service. Lack of price transparency: Historically, it has been difficult for consumers to compare prices. Tools like Payerprice can help bring more transparency by providing access to fee schedules for specific CPT codes and locations.