CPT code 99221: Initial hospital care, straightforward or low MDM, 40 minutes2026 Medicare rate & RVUs in Illinois
Report an initial inpatient or observation evaluation when decision making is straightforward or low, or qualifying practitioner time reaches 40 minutes.
CMS doesn’t publish an office rate for 99221 in Illinois.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
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On this page 9 sections
What 99221 covers
This is the lowest of the three initial hospital care levels. It covers an initial evaluation during a hospital inpatient or observation stay by a physician or other qualified health professional. Hospitalists, attending physicians, and consulting specialists may use this family for their initial service, depending on services already provided by practitioners of the same specialty and group. The evaluation may include a medically appropriate history and examination and a plan for a stable, uncomplicated problem.
Select 99221 using straightforward or low medical decision making, or at least 40 minutes of qualifying practitioner time on the encounter date. Document the decision making or total time used for selection. Qualifying time can include chart review, orders, care coordination, and documentation, whether or not performed on the unit. When the same practitioner provides an office or emergency department service before admitting the patient that day, report the initial hospital service rather than a separate earlier visit. For Medicare, the admitting practitioner of record appends modifier AI to identify the admission service.
This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.
Where 99221 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Chicago, IL | Unavailable | $83.15 |
| East St. Louis, IL | Unavailable | $79.82 |
| Rest of Illinois | Unavailable | $76.87 |
| Suburban Chicago, IL | Unavailable | $80.13 |
How the 99221 rate is calculated
Each of 99221’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.
How the rate is built · 99221
RVUs × geographic indexes × conversion factor
Work1.63
1.63 RVUs× 1.000 GPCI
Practice expense0.41
0.41 RVUs× 1.000 GPCI
Malpractice0.19
0.19 RVUs× 1.000 GPCI
Adjusted RVUs
2.2300
Conversion factor
$33.4009
Medicare rate
$74.48
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 99221
99221 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate.
Place of service · 99221
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
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99221 isn’t priced in this setting.
99221 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 99222Initial hospital visitModerate MDM or 55 minutes
- 99221 is supported by straightforward or low MDM, or at least 40 minutes when selecting by time. Moderate MDM or at least 55 minutes supports 99222.
- 99231Subsequent hospital visitStraightforward or low MDM, 25 minutes
- 99231 is for a subsequent visit after an initial service by a practitioner of the same specialty and group during the stay; 99221 is for their initial service.
- 99234Hospital careSame-day admission and discharge
- 99234 covers admission and discharge on the same date at the straightforward or low level when Medicare’s eight-hour stay requirement is met. For a shorter same-date stay, report the appropriate initial hospital care code.
- 99252Hospital consultationStraightforward level
- 99252 is an inpatient or observation consultation code for payers that recognize consultations when consultation requirements are met. For Medicare, select from the hospital care codes for the consultant’s initial service based on MDM or time.
99221 billing questions
When should this code be chosen instead of 99222?
Use 99221 for straightforward or low MDM, or when selecting by time and at least 40 minutes is documented. Moderate MDM or at least 55 minutes supports 99222.
Can a consultant bill this code for Medicare patients?
Yes, if this is the consultant’s initial hospital service and its MDM or time supports 99221. Medicare consultants use the initial hospital care family rather than inpatient consultation codes; the admitting practitioner of record adds modifier AI.
Is the same-day emergency department visit billable when the ED physician admits the patient?
When the same practitioner evaluates the patient in the emergency department and then admits them on the same date, report the initial hospital service rather than a separate ED visit. Include the qualifying same-day work in selecting its level.
Does this code apply to observation stays?
Yes. The initial hospital care family covers both inpatient admissions and observation stays.
Can prolonged service time be added to this level?
Medicare’s prolonged inpatient or observation service is paired with 99223, not 99221. If selecting by time, use a higher initial care level when its minimum time is met.
What documentation supports a time-based selection?
Record qualifying practitioner time on the encounter date, including activities such as reviewing results and coordinating care. Exclude time spent solely by clinical staff or on separately billed services.
Where these rates come from
FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.
CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027
Show the CMS file lines behind this rate
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