CPT 99254 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 | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital • 51 - Inpatient Psychiatric Facility |
| Common Modifiers | • None • GC - Service performed by resident under supervision • 25 - Significant, separately identifiable E/M service same day |
| Complexity Level | Moderate |
National average reimbursement for CPT 99254 by major payers:
$75.90
$144.52
$180.35
$180.99
| 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 99254 | ||||||
United | 99254 | $127.58 | 1073558433 - RINA SARKAR | 464596718 - (TX) DFW PRIMARY CARE PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $199.88 | 1043296502 - LIANXI LIAO | 751362682 - (TX) FORT WORTH HEART, P.A. | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99254 | $138.30 | 1144327875 - AKHTAR HUSSAIN | 261525357 - (TX) PROCARE INTERNAL MEDICINE ASSOCIATES PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $260.69 | 1689240541 - MUHAYMIN ABDUL-MOHEETH | 264562522 - SETON FAMILY OF DOCTORS | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $146.94 | 1063523223 - NEIL PHUNG | 510600056 - (TX) TEXAS CARDIOLOGY ASSOCIATES | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99254 | $269.67 | 1871851220 - ELECIA KIM | 752600832 - (TX) HEALTHTEXASMED PROVIDER | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $228.19 | 1710238514 - SAI SOUMYA KOTA | 752616977 - CHRISTUS TRINITY CLINIC | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $290.55 | 1598385544 - HARITH BALDAWI | 720276883 | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $158.52 | 1154945087 - ARAMIDE TIJANI | 465292740 | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $342.55 | 1124297866 - DR. TONY T CHUONG MD, PA, ARLINGTON PRIMARY CLINIC | 752893140 - (TX) DR TONY T CHUONG MD PA | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $240.03 | 1629569041 - SCOTT HATCHERSON | 752931720 | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $199.00 | 1962722876 - ADNAN SUBEI | 751667190 - (TX) NEUROLOGY CONSULTANTS OF DALLAS, P.A. | TX | Neurology Physician (2084N0400X) |
United | 99254 | $164.39 | 1518999226 - KAHTAN KAISSI | 760624114 - (TX) KAHTAN A KAISSI MD | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $228.19 | 1730591959 - MALASHA KHAN | 752616977 - CHRISTUS TRINITY CLINIC | TX | Internal Medicine Physician (207R00000X) |
United | 99254 | $223.11 | 1821261058 - MOULALI SHAIK | 752600873 - (TX) SHANNON 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 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 |
|---|---|---|
| 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) |
| 99252-CPT | 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-CPT | 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. |
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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