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See a sample rate comparisonCPT 99255 Fee Schedule
Last Verified: September 2026
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.
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
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management 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 |
| Medicaid Fee Schedule | View Medicaid rates for 99255 |
National average reimbursement for CPT 99255 by major payers:
$108.76
$183.16
$221.33
$220.33
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CPT 99255
5 of 25 sample ratesHigher to lower in this preview
Kimberly Idoko
Froedtert Manitowoc Medical Group LLC
$476.29Published rateGopal Katkoria
$265.82Published rateAli Abbas
$200.00Published rateAamir Siddiqi
Aamir J Siddiqi Md PLLC
$166.30Published rateHope Kidney Clinic, PLLC
$147.02Published rate
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Payer Contract Negotiation
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See a sample payer proposalCPT 99255 vs. Other Consultations Codes
The CPT 99255 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 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 |
|---|---|---|
| 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 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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