CPT 99231
Global XXX ActiveSbsq hosp ip/obs sf/low 25
CPT 99231 Billing & Documentation Guide
CPT code 99231 (Sbsq hosp ip/obs sf/low 25) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 1, a non-facility practice expense RVU of 0.24, and a malpractice RVU of 0.08, a total non-facility RVU of 1.32 and facility RVU of 1.32. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $44.74, though rates vary from $41.66 to $60.11 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99231, ensure documentation supports medical necessity and the specific components required for the code's level of service. For E/M codes, document MDM (medical decision-making) elements: problems addressed, data reviewed, and risk. For procedural codes, document the indication, technique, and any complications. Always verify NCCI edits before bundling 99231 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Active code (paid under MPFS)
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 1 units of 99231 for the same patient on the same date triggers automatic line denial unless an appropriate modifier and supporting documentation justify the higher quantity.
RVU Breakdown, CPT 99231
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 1 | 1 |
| Practice Expense RVU | 0.24 | 0.24 |
| Malpractice RVU | 0.08 | 0.08 |
| Total RVU | 1.32 | 1.32 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99231
State-level averages across all MAC localities. Non-facility rates typically apply to office-based services; facility rates apply to hospital outpatient / inpatient.
| State | Non-Facility | Facility | Range (Non-Fac) | Localities |
|---|---|---|---|---|
| California | $45.53 | $45.53 | $44.19 - $50.07 | 29 |
| Florida | $46.64 | $46.64 | $45.08 - $48.5 | 3 |
| Georgia | $44.3 | $44.3 | $43.74 - $44.85 | 2 |
| Illinois | $46.37 | $46.37 | $44.9 - $47.82 | 4 |
| Michigan | $44.69 | $44.69 | $43.74 - $45.64 | 2 |
| North Carolina | $42.59 | $42.59 | $42.59 - $42.59 | 1 |
| New York | $47.56 | $47.56 | $42.89 - $50.03 | 5 |
| Ohio | $43.41 | $43.41 | $43.41 - $43.41 | 1 |
| Pennsylvania | $44.41 | $44.41 | $43.28 - $45.53 | 2 |
| Texas | $43.96 | $43.96 | $43.18 - $45.3 | 8 |
Source: CMS PFSRVU 2026 · Updated 2026-04-01. Full locality-level detail available for all 53 states, contact us for custom reports.
NCCI Bundling Edits, CPT 99231
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99231 on the same date of service, review the modifier indicator and payer policy before submission.
| Partner Code | Relationship | Modifier Allowed | Rationale |
|---|---|---|---|
| 0074T | Column 1 (primary), can be billed with modifier | 9 | CPT Manual or CMS manual coding instruction |
| 0115T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0116T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0359T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0360T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0361T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0362T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0363T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
| 0364T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 99231
What does CPT code 99231 mean? +
CPT code 99231 represents: Sbsq hosp ip/obs sf/low 25. It's in the E/M category with a global period of XXX.
What is the Medicare reimbursement for CPT 99231? +
The 2026 Medicare national average non-facility payment for CPT 99231 is $44.74. Rates range from $41.66 to $60.11 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99231? +
E/M codes commonly use modifier 25 (significant separately identifiable E/M on same day as a procedure), 57 (decision for major surgery), 24 (unrelated E/M during global period), 95 (synchronous audio+video telehealth), 93 (audio-only telehealth), and AI (principal physician of record on admission). Surgical modifiers like 50, 51, 59 do not apply to E/M.
What bundling edits apply to CPT 99231? +
This code has 10 NCCI PTP bundling relationships. See the NCCI Bundling section below for full list.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on May 31, 2026.
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