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See a sample rate comparisonCPT 99455 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.
Work Related Disability Exam, Work Related Or Medical Disability Examination By The Treating Physician That Includes Completion Of A Medical History Commensurate With The Patient S Condition Performance Of An Examination Commensurate With The Patient S Condition Formulation Of A Diagnosis Assessment Of Capabilities And Stability And Calculation Of Impairment Development Of Future Medical Treatment Plan And Completion Of Necessary Documentation Certificates And Report
| Key Fact | Detail |
|---|---|
| Service Type | Evaluation and Management Special Evaluation and Management Services |
| Common Place of Service | 20 - Urgent Care Facility 11 - Office |
| Common Modifiers | V4 |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 99455 |
| Medicaid Fee Schedule | $174.82 median of the 3 states in the free preview · View Medicaid rates for 99455 |
National average reimbursement for CPT 99455 by major payers:
$177.61
$126.59
$94.68
$255.49
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CPT 99455
5 of 25 sample ratesHigher to lower in this preview
Crosbyton Clinic Hospital
$1,272.00Published rateEvelyn Cavalier
Nyc Podiatric Medicine And Surgery PC
$60.00Published rateAll Ways Homecare Inc
$55.00Published rateAll Ways Homecare Inc
$35.00Published rateAll Ways Homecare Inc
$35.00Published rate
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Payer Contract Negotiation
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See a sample payer proposalCPT 99455 vs. Other Special Evaluation and Management Services Codes
The CPT 99455 code is part of the Evaluation and Management services used for Special Evaluation and Management Services. 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 99455 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 |
|---|---|---|
| 99450-CPT | Low | Basic Life Disability Exam, Basic Life And Or Disability Examination That Includes: Measurement Of Height Weight And Blood Pressure Completion Of A Medical History Following A Life Insurance Pro Forma Collection Of Blood Sample And Or Urinalysis Complying With Chain Of Custody Protocols And Completion Of Necessary Documentation Certificates. |
| 99455-CPT | Low | Work Related Disability Exam, Work Related Or Medical Disability Examination By The Treating Physician That Includes Completion Of A Medical History Commensurate With The Patient S Condition Performance Of An Examination Commensurate With The Patient S Condition Formulation Of A Diagnosis Assessment Of Capabilities And Stability And Calculation Of Impairment Development Of Future Medical Treatment Plan And Completion Of Necessary Documentation Certificates And Report |
| 99456-CPT | Low | Disability Examination, Work Related Or Medical Disability Examination By Other Than The Treating Physician That Includes Completion Of A Medical History Commensurate With The Patient S Condition Performance Of An Examination Commensurate With The Patient S Condition Formulation Of A Diagnosis Assessment Of Capabilities And Stability And Calculation Of Impairment Development Of Future Medical Treatment Plan And Completion Of Necessary Documentation Certificates And Report |
| 99490-CPT | Low | Chrnc Care Mgmt Staff 1st 20, Chronic Care Management Services With The Following Required Elements Multiple Two Or More Chronic Conditions Expected To Last At Least 12 Months Or Until The Death Of The Patient Chronic Conditions That Place The Patient At Significant Risk Of Death Acute Exacerbation Decompensation Or Functional Decline Comprehensive Care Plan Established Implemented Revised Or Monitored First 20 Minutes Of Clinical Staff Time Directed By A Physician Or Other Qualified Health Care Professional Per Calendar Month |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 99455. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 99455 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 stands for Current Procedural Terminology. CPT codes are a standardized set of medical codes used by healthcare providers, including physicians and hospitals, to describe the medical, surgical, and diagnostic services they provide to patients. These codes are crucial for billing, claims processing, and for consistently communicating about medical procedures and services.
To find an estimated cost for a specific medical procedure or service, you should consider factors like the CPT code for the service, your specific geographic location, and your insurance plan. For a personalized estimate, you can utilize tools like Payerprice, which offers a fee schedule lookup tool allowing users to search for costs using CPT codes and specific locations. It's also recommended to contact your insurance provider directly to understand your specific benefits, deductibles, copayments, and potential out-of-pocket costs for the service.
An in-network provider has a contract with your health insurance company to provide services at pre-negotiated rates, which typically results in lower out-of-pocket costs for you. An out-of-network provider does not have such an agreement, meaning your insurance may cover a smaller portion of the cost, or you might be responsible for a higher percentage of the bill, potentially leading to greater out-of-pocket expenses.
Yes, you can dispute a medical bill if you believe there's an error. First, carefully review the bill and compare it with your Explanation of Benefits (EOB) from your insurance company. If discrepancies are found, contact the healthcare provider's billing department to clarify or dispute the charges. If direct resolution isn't possible, you can then reach out to your insurance company for assistance or consider contacting your state's department of insurance or consumer protection agency.
These are common terms related to your health insurance costs: - **Deductible:** The amount you must pay for covered healthcare services before your insurance plan starts to pay. - **Copay (Copayment):** A fixed amount you pay for a covered healthcare service after you've met your deductible (if applicable). - **Coinsurance:** Your share of the cost of a healthcare service, calculated as a percentage (e.g., 20%) of the allowed amount for the service, after you've met your deductible.