CPT 99455 Fee Schedule
Last Updated: April 2025
Work Related Or Medical Disability Examination By The Treating Physician That Includes; Completion Of A Medical History Commensurate With The Patients Condition; Performance Of An Examination Commensurate With The Patients 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
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 • Special Evaluation and Management Services |
| Common Place of Service | • 20 - Urgent Care Facility • 11 - Office • None |
| Common Modifiers | • None • None • V4 |
| Complexity Level | Moderate |
National average reimbursement for CPT 99455 by major payers:
$115.47
$N/A
$94.69
$260.01
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.
CPT 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.
| CPT Code | Complexity Level | Description |
|---|---|---|
| 99350 | High | Home Or Residence Visit For The Evaluation And Management Of An 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 60 Minutes Must Be Met Or Exceeded.(Desc Rvsd 1/1/23) |
| 99450 | Moderate | 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 | Moderate | Work Related Or Medical Disability Examination By The Treating Physician That Includes; Completion Of A Medical History Commensurate With The Patients Condition; Performance Of An Examination Commensurate With The Patients 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 |
| 99456 | Moderate | Work Related Or Medical Disability Examination By Other Than The Treating Physician That Includes; Completion Of A Medical History Commensurate With The Patients Condition; Performance Of An Examination Commensurate With The Patients 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 |
See what providers are getting paid in 2024 for 99455:
CPT 99455 Fee Schedule & Reimbursement Rates
The CPT 99455 fee schedule varies by payer type. Below are Medicare rates for 2024 and average in-network rates by state across major payers:
| Code | Medicare Rate | Avg. Cigna National Rate | More Info |
|---|---|---|---|
| 99350 | $183.75 | ||
| 99450 | $228.24 | ||
| 99455 | $260.01 | ||
| 99456 | $343.08 | ||
| 99490 | $62.58 | $91.60 | |
| 99499 | $188.67 |
Reimbursement rates depend on provider contracts, region, and payer. Always verify rates with your insurance provider or medical billing department.
What is price transparency?
The Price Transparency Rule is a federal law that took effect in July 2022, requiring all commercial payers to publicly disclose their prices through machine-readable files (MRFs). In short, this regulation mandates that insurance companies make healthcare costs transparent to the public.
Our data comes directly from these insurer-posted MRFs, ensuring compliance with the Price Transparency Rule. While PayerPrice is working toward a future where providers and payers collaborate for 100% upfront price certainty, it's important to acknowledge that data limitations and occasional errors may exist.
Healthcare Price Transparency Rule
cms.govConsumer Guide To Healthcare Prices
aha.orgGlossary of Healthcare Terms
healthcare.govUnlock access to price transparency insights today.
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