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See a sample rate comparisonCPT 99254 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 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
| 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 | GC - Service performed by resident under supervision 25 - Significant, separately identifiable E/M service same day |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 99254 |
| Medicaid Fee Schedule | $117.38 median of the 7 states in the free preview · View Medicaid rates for 99254 |
National average reimbursement for CPT 99254 by major payers:
$75.90
$144.52
$180.35
$177.91
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CPT 99254
5 of 25 sample ratesHigher to lower in this preview
Dr. Tony T Chuong Md, PA, Arlington Primary Clinic
Dr Tony T Chuong Md PA
$342.55Published rateLindsay Sonstein
$237.66Published rateLianxi Liao
Fort Worth Heart, P.A.
$199.88Published rateAramide Tijani
$158.52Published rateRina Sarkar
Dfw Primary Care PLLC
$127.58Published rate
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Payer Contract Negotiation
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See a sample payer proposalCPT 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.
| 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 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.
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Frequently Asked Questions
CPT code 99254 is an Evaluation and Management (E/M) service code specifically for Consultations, designating a moderate-complexity encounter. When comparing it to other consultation codes (99251 to 99255), the key distinctions are: * **Provider Time:** CPT 99254 involves a greater amount of provider time. * **Medical Decision-Making (MDM):** It requires a moderate level of medical decision-making, often encompassing multiple diagnoses, medication management, or the interpretation of various tests. * **Documentation:** Due to its moderate complexity, it mandates more detailed documentation. * **Reimbursement:** It typically results in higher reimbursement compared to lower-level consultation codes that involve less time and simpler assessments. For specific reimbursement rates or detailed documentation requirements for CPT 99254 and how it compares to other consultation codes in a particular geographic area or with a specific payer, it is recommended to use Payerprice's fee schedule lookup tool, which allows users to search with CPT codes and locations.