CPT Code 99245Complete Billing & Coding Guide (2026)Office/outpatient consltj new/est hi 55
About CPT 99245
CPT 99245 is a Current Procedural Terminology code in the E/M category maintained by the American Medical Association. The CMS short descriptor reads "Off/op consltj new/est hi 55". For the full AMA long descriptor and clinical guidance, refer to the current CPT code manual.
Documentation specificity, correct ICD-10 linkage, and modifier accuracy determine whether 99245 pays cleanly or triggers a denial. Verify CMS National Physician Fee Schedule status, applicable Medicare LCDs, and any payer-specific medical policies before submission.
When billing 99245 with a procedure on the same day, use modifier 25 to indicate a significant, separately identifiable E/M service. Documentation must support the separate work, including a distinct chief complaint or HPI section if applicable.
Code Properties
RVU Breakdown
Every CPT code’s Medicare payment is calculated from three Relative Value Unit components: physician work, practice expense, and malpractice. Together they multiply by the conversion factor to produce the payment amount.
Payment = Total RVU × Conversion Factor ($33.4009) × Geographic Adjustment (GPCI). National averages shown. Actual payment varies by locality.
Medicare Payment by State
Medicare adjusts payment by locality based on GPCI (Geographic Practice Cost Index). Higher cost-of-living areas like California and New York pay more. Rural states pay less. Top 12 states shown.
Showing top 12 of 53 states. Full locality data available in CMS PFS Locality file.
NCCI Bundling Edits
10 pairsThese codes trigger National Correct Coding Initiative edits when billed with 99245. An indicator of 0 means the pair cannot be unbundled. Indicator 1 means modifier 59 or X-modifiers may allow separate billing with supporting documentation.
99245 + 0362T: bundled, modifier may bypass (indicator 1)
The most-asked bundling question on this code. Verdict pulled from the current NCCI quarterly file.
Modifier indicator 1 means a modifier may bypass the edit when the clinical scenario supports a distinct, separately identifiable service. Most billers default to modifier 59, but payers prefer the more specific X-modifiers (XE, XS, XP, XU) and pay them with less audit scrutiny. Documentation must establish the separation factor.
Misuse of Column Two code with Column One code
Billing 99245 alongside a bundled code without the correct modifier generates CARC 97 denials. Payers often flag these as audit risks. Document medical necessity for the separate service and apply modifier 59 or the appropriate X-modifier (XE, XS, XP, XU) only when clinically justified.
Misuse of Column Two code with Column One code
Misuse of Column Two code with Column One code
Misuse of Column Two code with Column One code
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
CPT Manual or CMS manual coding instruction
E/M-with-procedure CO-97 denials are usually a modifier 25 documentation problem, not a bundling truth. Distinct chief complaint, distinct HPI, distinct A/P sections in the chart make the modifier 25 defensible. We audit every E/M line billed with a same-day procedure before submission.
Denied on 99245 + 0362T with the wrong modifier? Send us the EOB.
Most bundling denials on 99245 are recoverable when an X-modifier replaces a generic mod 59 and the chart supports a distinct service. A coder will read the EOB and the operative or procedure note for you.
Remove patient name, DOB, and member ID before pasting.
Applicable Modifiers
Modifiers commonly paired with 99245 based on its category. Apply only when the clinical circumstance warrants. Incorrect modifier use is a top audit target.
Modifier 25 on E/M plus same-day procedure is the most-audited modifier in physician billing. UnitedHealthcare, Anthem, and several BCBS plans run automated post-pay review on these claims. We audit every modifier 25 application against the chart before submission.
Supporting ICD-10 Diagnoses
These diagnosis codes commonly support medical necessity for CPT 99245. Using the correct ICD-10 prevents CARC 50 denials. Payer rejects when the diagnosis doesn’t support the procedure.
E/M CO-50 denials are typically about diagnosis-procedure linkage. Stale or generic ICD-10 codes attached to 99245 fail medical-necessity review. We verify diagnosis specificity at the coding stage.
Find the revenue leakage in your 99245 claims.
Wrong modifier, missing documentation, bundling without justification, stale ICD-10 linkage: these are the silent revenue killers on E/M claims. Our AAPC-certified team audits your last 90 days of 99245 claims, surfaces the recoverable dollars, and appeals them. Free, no obligation.
Losing revenue on CPT 99245? We’ll find it.
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Related CPT Codes
Codes in the same family as 99245
Everything about CPT 99245
What does CPT code 99245 cover?
CPT 99245 is a Current Procedural Terminology code in the E/M category maintained by the American Medical Association. The CMS short descriptor reads "Off/op consltj new/est hi 55". For the full AMA long descriptor and clinical guidance, refer to the current CPT code manual.
What is the Medicare payment for CPT 99245?
The national average Medicare payment for CPT 99245 is approximately $209.42 in a non-facility setting and $178.69 in a facility setting. Actual payment varies by locality based on GPCI adjustments. Total RVU is 6.27 with a conversion factor of $33.4009.
What is the global period for CPT 99245?
CPT 99245 has no global period (indicator XXX). Because it's an E/M code, there are no post-operative day restrictions. You can bill 99245 on the same day as a procedure with modifier 25 (significant, separately identifiable E/M), or during another code's post-op period with modifier 24 (unrelated E/M during global period).
What codes bundle with CPT 99245?
CPT 99245 has NCCI Procedure-to-Procedure edits with 10+ codes including 0362T, 0373T, 0469T. Modifier indicator 0 means the edit cannot be bypassed. Indicator 1 means modifier 59 or X-modifiers may allow separate billing with documentation.
CPT codes and descriptions are copyright of the American Medical Association. RVU values reflect current CMS publications. Actual payment varies by locality. Commercial payer rates vary by contract.
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We audit your last 90 days of claims and surface the revenue leakage: wrong modifiers, missed bundling appeals, ICD-10 specificity gaps. AAPC-certified coders. 2.49% of collections. No setup fees.