CPT 99255 Fee Schedule
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.
| Key Fact | Detail |
|---|---|
| Service Type | New or Established Patient Inpatient or Observation Consultations |
| Common Place of Service | 21 - Inpatient Hospital 22 - On Campus Outpatient Hospital 23 - Emergency Room |
| Common Modifiers | None GC - Service performed by resident under supervision 25 - Significant, separately identifiable E/M service same day |
| Complexity Level | High |
| Medicare Fee Schedule | View Medicare rates for 99255 |
National average reimbursement for CPT 99255 by major payers:
$108.76
$183.16
$221.33
$220.33
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 99255 | $155.91 | 1205875721 - JOSE PENA | 223875437 - (TX) DONNA MEDICAL CLINIC, P.A. | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $304.20 | 1841293370 - JAMES GRATTAN | 752651583 - (TX) CARDIOLOGISTS OF LUBBOCK, PA | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99255 | $214.94 | 1295907178 - NIANGUI WANG | 260373971 - (TX) DALLAS NEUROSCIENCE PA | TX | Neurology Physician (2084N0400X) |
United | 99255 | $154.66 | 1902881535 - WILLIAM ATLAS | 471780948 - (TX) WILLIAM A ATLAS MD PA | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $155.91 | 1023002144 - ELENA GUROVA | 204698063 - (TX) ELENA GUROVA MD PA | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $285.73 | 1326627514 - MERY BARTL | 352030653 - ARNETT CLINIC LLC | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $166.30 | 1669485546 - RAYMOND LITTLE | 475121610 - (TX) NIRP PASADENA PLLC | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99255 | $200.00 | 1053382754 - PRAKASH HEGDE | 760221050 | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $166.30 | 1487746020 - HOUSTON CARDIOVASCULAR ASSOC INC | 741941710 | TX | Cardiovascular Disease Physician (207RC0000X) |
United | 99255 | $147.02 | 1386842391 - HOPE KIDNEY CLINIC, PLLC | 208646412 - (TX) HOPE KIDNEY CLINIC, PLLC | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $219.52 | 1033741616 - CENTERWELL SENIOR PRIMARY CARE (TX) PA, CENTERWELL SENIOR PRIMARY CARE- TIDWELL | 301236218 | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $283.33 | 1992190342 - HAFSA ZIA | 204923281 - MEMORIAL HERMANN MEDICAL GROUP | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $200.00 | 1811900285 - ALI ABBAS | 760221050 | TX | Internal Medicine Physician (207R00000X) |
United | 99255 | $166.30 | 1275503575 - AAMIR SIDDIQI | 202612517 - (TX) AAMIR J SIDDIQI MD PLLC | TX | Neurology Physician (2084N0400X) |
United | 99255 | $476.29 | 1003080896 - KIMBERLY IDOKO | 871785388 - (WI) FROEDTERT MANITOWOC MEDICAL GROUP LLC | TX | Neurology Physician (2084N0400X) |
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 99255 vs. Other Inpatient or Observation Consultations Codes
The CPT 99255 code is part of the New or Established Patient services used for Inpatient or Observation 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 99255 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 |
| 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 |
| 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 99255. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99255 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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