CPT code 99242: Office consultation, straightforward level2026 Medicare rate & RVUs

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 99242 covers

Code 99242 identifies an office or other outpatient consultation for a new or established patient at the straightforward medical decision-making level. A physician or other qualified health care professional evaluates the patient in response to a request for an opinion or advice on a clinical question and communicates the assessment to the requester. The code carries a 20-minute time designation.

Medicare lists 99242 as status I: it is not valid for Medicare, which uses a different code to report and pay for the service. The 20-minute designation identifies the consultation service level; it does not make 99242 a Medicare-valid reporting code. The consultation family distinguishes outpatient consultations from inpatient or observation consultations and from ordinary office or outpatient E/M visits.

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 99242 pays more and less

The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.

109 of 109 payment localities

99242 rates by state

Office rate range in each state. Select a state to see its payment localities.

How the 99242 rate is calculated

Each of 99242’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.

Payment rules and modifiers for 99242

99242 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.

99242 compared with similar codes

How to choose

99243Office consultationLow MDM, 30 minutes

Both are office or outpatient consultations. 99242 has straightforward decision-making and a 20-minute designation; 99243 has low decision-making complexity and a 30-minute designation.

99245Office consultationHigh level, 55 minutes

99245 is a higher outpatient consultation level, with high decision-making complexity and a 55-minute designation; 99242 has straightforward decision-making and a 20-minute designation.

99252Hospital consultationStraightforward level

99252 is an inpatient or observation consultation code. 99242 is for an office or outpatient consultation.

99213Office visitEstablished patient, low complexity

99213 describes an established-patient office or outpatient E/M visit, while 99242 describes an outpatient consultation.

Codes related to 99242

Related codes aren’t interchangeable: bill the code that matches the service performed.

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

Open CMS sourceHow we calculate rates