CPT 99254 Fee Schedule
Last Updated: April 2025
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.
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 | • 21 - Inpatient Hospital • 22 - On Campus-Outpatient Hospital • 51 - Inpatient Psychiatric Facility |
| Common Modifiers | • None • GC - Service has been performed in part by a resident under the direction of a teaching physician • 25 - Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service |
| Complexity Level | Moderate |
National average reimbursement for CPT 99254 by major payers:
$201.39
$197.98
$180.37
$179.80
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99254. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99254 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.
CPT 99254 vs. Other Consultations Codes
The CPT 99254 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 99254 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.
| CPT Code | Complexity Level | 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) |
| 99252 | Low | 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. (Desc Rvsd 1/1/23) |
| 99254 | Moderate | 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. |
See what providers are getting paid in 2024 for 99254:
CPT 99254 Fee Schedule & Reimbursement Rates
The CPT 99254 fee schedule varies by payer type. Below are Medicare rates for 2024 and average in-network rates by state across major payers:
| Code | Medicare Rate | Avg. Cigna National Rate | More Info |
|---|---|---|---|
| 99242 | $74.90 | $98.74 | |
| 99243 | $112.18 | $136.45 | |
| 99252 | $70.24 | $84.83 | |
| 99253 | $98.53 | $125.53 | |
| 99254 | $136.81 | $179.80 | |
| 99255 | $184.08 | $223.57 |
Reimbursement rates depend on provider contracts, region, and payer. Always verify rates with your insurance provider or medical billing department.
What is price transparency?
The Price Transparency Rule is a federal law that took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). In short, this regulation mandates that insurance companies make healthcare costs transparent to the public.
Our data comes directly from these insurer-posted MRFs, ensuring compliance with the Price Transparency Rule. While PayerPrice is working toward a future where providers and payers collaborate for 100% upfront price certainty, it's important to acknowledge that data limitations and occasional errors may exist.
Healthcare Price Transparency Rule
cms.govConsumer Guide To Healthcare Prices
aha.orgGlossary of Healthcare Terms
healthcare.govUnlock access to price transparency insights today.
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