CPT code 99255: Inpatient consultation, high level2026 Medicare rate & RVUs in Maryland
A high-level inpatient or observation consultation documents a requested evaluation of a specific problem by a physician or qualified health professional.
CMS doesn’t publish an office rate for 99255 in Maryland.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
Your location
On this page 9 sections
What 99255 covers
99255 represents a high-level consultation for a new or established patient receiving inpatient or observation care. Another clinician requests an opinion or recommendations about the patient’s condition or management. The consultant evaluates the patient and communicates findings and recommendations to the requesting clinician. Its consultative purpose distinguishes it from routine ongoing hospital care.
Medicare assigns 99255 status I: the code is not valid for Medicare, and Medicare uses a different code to report and pay for the service. For Medicare claims, report the hospital evaluation and management service that matches the encounter instead. Depending on the service performed, an initial hospital care code such as 99221–99223 or a subsequent hospital care code such as 99231–99233 may be appropriate. The high consultation level does not make 99255 valid for Medicare.
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 99255 pays more and less in Maryland
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
| Payment locality | Office | Facility |
|---|---|---|
| Baltimore area, MD | Unavailable | Unavailable |
| Rest of Maryland | Unavailable | Unavailable |
| Washington, DC area | Unavailable | Unavailable |
How the 99255 rate is calculated
Each of 99255’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 · 99255
RVUs × geographic indexes × conversion factor
Work3.86
3.86 RVUs× 1.000 GPCI
Practice expense1.44
1.44 RVUs× 1.000 GPCI
Malpractice0.23
0.23 RVUs× 1.000 GPCI
Adjusted RVUs
5.5300
Conversion factor
$33.4009
Medicare rate
$184.71
Every GPCI starts at 1.000, the national rate. Enter a ZIP or drag a slider.
Payment rules and modifiers for 99255
99255 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 · 99255
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
POS 11 · non-facility rate · national
—
99255 isn’t priced in this setting.
99255 compared with similar codes
Compare codes · National
5 codes, side by side
How to choose
- 99254Hospital consultationModerate, 60-minute level
- Choose 99254 for a moderate-level inpatient or observation consultation; 99255 represents the high level.
- 99223Initial hospital visitHigh decision making or 75 minutes
- 99223 reports high-level initial hospital care, not a consultation. For Medicare, use an appropriate hospital E/M code based on the service performed rather than 99255.
- 99245Office consultationHigh level, 55 minutes
- 99245 is the high-level consultation code for an office or other outpatient setting; 99255 is for inpatient or observation care.
- 99233Hospital follow-up visitSubsequent day, high complexity
- 99233 reports subsequent hospital care. 99255 describes a consultation and is not valid for Medicare.
99255 billing questions
Can 99255 be billed to Medicare?
No. Medicare classifies 99255 as not valid for Medicare and uses a different code to report and pay for the service.
How does 99255 differ from 99254?
Both describe inpatient or observation consultations. 99255 is the high-level sibling; 99254 represents the moderate level.
Should a Medicare inpatient consultation be reported with 99223?
Use 99223 when the service meets the requirements for initial hospital care. The appropriate Medicare E/M code depends on the service performed.
What documentation supports a consultation?
Document the request for an opinion, the clinical evaluation, the consultant’s recommendations, and communication of the findings to the requesting clinician.
Does a modifier make 99255 payable by Medicare?
No. Medicare classifies 99255 as not valid for Medicare; a modifier does not change that code status.
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
Fee sheets
Put 99255 and the rest of your codes on one sheet
Your codes at your locality, with payer contracts beside Medicare.
Build my fee sheet