CPT 99254
Global XXXIp/obs cnsltj new/est mod 60
CPT 99254 Billing & Documentation Guide
CPT code 99254 (Ip/obs cnsltj new/est mod 60) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 2.72, a non-facility practice expense RVU of 1.23, and a malpractice RVU of 0.17, a total non-facility RVU of 4.12 and facility RVU of 4.12. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $140.45, though rates vary from $129.07 to $183.16 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99254, 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 99254 with related codes; this code has 10 PTP bundling relationships on file (see table below).
Payment Status & Global Period
Invalid for Medicare; not separately payable
No global period (E/M and other non-procedural services)
MUE Limit (Medically Unlikely Edits)
Submitting more than 0 units of 99254 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 99254
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 2.72 | 2.72 |
| Practice Expense RVU | 1.23 | 1.23 |
| Malpractice RVU | 0.17 | 0.17 |
| Total RVU | 4.12 | 4.12 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99254
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 | $145.8 | $145.8 | $140.47 - $163.13 | 29 |
| Florida | $143.12 | $143.12 | $138.66 - $147.98 | 3 |
| Georgia | $136.97 | $136.97 | $134.26 - $139.68 | 2 |
| Illinois | $141.72 | $141.72 | $137.23 - $145.81 | 4 |
| Michigan | $137.42 | $137.42 | $134.77 - $140.07 | 2 |
| North Carolina | $132.81 | $132.81 | $132.81 - $132.81 | 1 |
| New York | $148.71 | $148.71 | $133.87 - $156.06 | 5 |
| Ohio | $134.08 | $134.08 | $134.08 - $134.08 | 1 |
| Pennsylvania | $137.98 | $137.98 | $133.93 - $142.03 | 2 |
| Texas | $137.07 | $137.07 | $133.51 - $140.19 | 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 99254
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99254 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 |
| 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 |
| 0365T | Column 1 (primary), can be billed with modifier | Yes | Misuse of Column Two code with Column One code |
Frequently Asked Questions, CPT 99254
What does CPT code 99254 mean? +
CPT code 99254 represents: Ip/obs cnsltj new/est mod 60. It's in the E/M category with a global period of XXX.
What is the Medicare reimbursement for CPT 99254? +
The 2026 Medicare national average non-facility payment for CPT 99254 is $140.45. Rates range from $129.07 to $183.16 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99254? +
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 99254? +
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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