CPT 99281
Global XXX ActiveEmr dpt vst mayx req phy/qhp
CPT 99281 Billing & Documentation Guide
CPT code 99281 (Emr dpt vst mayx req phy/qhp) is classified under E/M with a global period indicator of XXX. The 2026 Medicare Physician Fee Schedule assigns a work RVU of 0.25, a non-facility practice expense RVU of 0.05, and a malpractice RVU of 0.03, a total non-facility RVU of 0.33 and facility RVU of 0.33. With the current conversion factor of $33.4009, the national average non-facility reimbursement is approximately $11.12, though rates vary from $10.26 to $14.86 based on MAC locality and Geographic Practice Cost Indices (GPCIs).
When billing 99281, 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 99281 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 99281 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 99281
| Component | Non-Facility | Facility |
|---|---|---|
| Work RVU | 0.25 | 0.25 |
| Practice Expense RVU | 0.05 | 0.05 |
| Malpractice RVU | 0.03 | 0.03 |
| Total RVU | 0.33 | 0.33 |
| Conversion Factor | $33.4009 | |
2026 Medicare Reimbursement by State, CPT 99281
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 | $11.17 | $11.17 | $10.86 - $12.21 | 29 |
| Florida | $11.97 | $11.97 | $11.45 - $12.62 | 3 |
| Georgia | $11.16 | $11.16 | $11.03 - $11.28 | 2 |
| Illinois | $11.91 | $11.91 | $11.44 - $12.39 | 4 |
| Michigan | $11.33 | $11.33 | $11.01 - $11.65 | 2 |
| North Carolina | $10.55 | $10.55 | $10.55 - $10.55 | 1 |
| New York | $11.97 | $11.97 | $10.64 - $12.73 | 5 |
| Ohio | $10.89 | $10.89 | $10.89 - $10.89 | 1 |
| Pennsylvania | $11.13 | $11.13 | $10.83 - $11.43 | 2 |
| Texas | $10.97 | $10.97 | $10.8 - $11.45 | 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 99281
Procedure-to-procedure (PTP) edits. If you bill any of these codes with 99281 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 99281
What does CPT code 99281 mean? +
CPT code 99281 represents: Emr dpt vst mayx req phy/qhp. It's in the E/M category with a global period of XXX.
What is the Medicare reimbursement for CPT 99281? +
The 2026 Medicare national average non-facility payment for CPT 99281 is $11.12. Rates range from $10.26 to $14.86 across 53 states depending on MAC locality and GPCIs.
What modifiers can I use with CPT 99281? +
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 99281? +
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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