CPT 99241: Office Consultation, Problem-Focused Visit

Commercial payers pay $85 on average nationally for this procedure.

CPT code 99241 describes an office consultation for a new or established patient that requires a problem-focused history, problem-focused examination, and straightforward medical decision making; the service type is office consultation, typically provided in an office or outpatient clinic setting with about 15 minutes face-to-face with the patient and/or family for usually self-limited or minor presenting problems.

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National Reimbursement Benchmarks

Across national commercial contracts, BUCA serves as the average commercial reference with a mean of $85.00 and interquartile spread from $66.30 to $95.10, yielding an IQR of $28.80. Blue Cross Blue Shield (BCBS) and UnitedHealth Group both show notable dispersion: BCBS has an IQR from $57.20 to $91.80 (IQR = $34.60) and UnitedHealth Group’s IQR runs $49.80 to $68.00 (IQR = $18.20). Cigna sits higher on average with a mean of $114.60 and a tighter upper quartile clustering at $129.00 versus a $101.00 first quartile (IQR = $28.00). Cigna also exhibits the highest median among the named payers at $101.00.

Comparing quartile spreads, Blue Cross Blue Shield has the widest IQR at $34.60, indicating greater midrange variability, while UnitedHealth Group is the tightest at $18.20, suggesting more consistent contract rates in the interquartile band. BUCA’s IQR of $28.80 and Cigna’s IQR of $28.00 place them in the middle in terms of dispersion. Where present, payer-specific maxima and minima further contextualize the ranges: BCBS’s max of $193.70 and UnitedHealth Group’s max of $185.80 sit well above their respective medians, and Cigna’s min of $89.40 is above several payer medians.

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CPT 99241: Office Consultation, Problem-Focused Visit

Commercial payers pay $85 on average nationally for this procedure.

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Sign up for cpt 99241 policy alerts

Get alerted when payer policies referencing 99241 are released or updated.

Monitor payer policy activity

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National Reimbursement Benchmarks

National Payer Mean Reimbursement Rates

Clinical & Coding Specifications

Clinical Context

A 34-year-old patient presents to a primary care clinic for an office consultation regarding intermittent cough and new-onset fatigue. The patient is new to the practice and was referred by an urgent care physician for evaluation of persistent symptoms that have not improved over two weeks. The clinician performs a focused history targeting respiratory, constitutional, and relevant systems, a problem-focused physical examination emphasizing chest and oropharynx, and formulates straightforward medical decision making that may include symptomatic treatment, brief diagnostic testing orders (e.g., chest radiograph or point-of-care testing), and coordination of care with a pulmonologist if needed. Face-to-face time is approximately 15 minutes. Typical documentation includes reason for visit, history of present illness limited to the presenting problem, focused review of systems related to cough and fatigue, focused exam findings, assessment with one to three possible diagnoses (for example, R05, R53.83), and plan including counseling, prescriptions, and any referrals or follow-up instructions.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99201`	Office or other outpatient visit for the evaluation and management of a new patient	Alternative lower-complexity new patient visit; used when presenting problem and services meet its requirements rather than `99241`.
`99212`	Office or other outpatient visit for the evaluation and management of an established patient	Used for established patients with a problem-focused visit of lower complexity than required for `99241`.
`99242`	Office or other outpatient consultation for a new or established patient	Higher-level consultation code (moderate complexity) closely related; use when history/exam/MDM exceed `99241` requirements.
`99354`	Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service	Use when face-to-face time for the consult extends beyond the usual ~15 minutes and prolonged services are documented.

Related Modifiers

8 rows

Modifier	Description	When to Use
22	Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…	- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
23	Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…	- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
52	Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…	- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
53	Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…	- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
54	Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…	- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
55	Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…	- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
56	Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…	- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
62	Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…	- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207Q00000X	Family Medicine Physician	Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
207R00000X	Internal Medicine Physician	A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
208D00000X	General Practice Physician	A physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
2080P0207X	Pediatric Hematology & Oncology Physician	A pediatrician trained in the combination of pediatrics, hematology and oncology to recognize and manage pediatric blood disorders and cancerous disea…
3418M1130X	Military or U.S. Coast Guard Water Transport Ambulance	Vehicle and staff for patient emergency or non-emergency sea/water transport
2080B0002X	Pediatric Obesity Medicine Physician	A physician who specializes in the treatment of obesity demonstrates competency in and a thorough understanding of the treatment of obesity and the ge…
207VX0000X	Obstetrics Physician	A physician who specializes in diagnosis, treatment, and management of patients with obstetric conditions.
2084H0002X	Hospice and Palliative Medicine (Psychiatry & Neurology) Physician	A psychiatrist or neurologist with special knowledge and skills to prevent and relieve the suffering experienced by patients with life-limiting illnes…

Related ICD-10-CM Codes

5 rows

ICD-10-CM Code	Description
Z01.419	Encounter for gynecological examination (general) (routine) without abnormal findings
R05
R53.83	Other fatigue
Z00.00	Encounter for general adult medical examination without abnormal findings
R10.9	Unspecified abdominal pain

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

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Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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Clinical & Coding Specifications

Clinical Context

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`99201`	Office or other outpatient visit for the evaluation and management of a new patient	Alternative lower-complexity new patient visit; used when presenting problem and services meet its requirements rather than `99241`.
`99212`	Office or other outpatient visit for the evaluation and management of an established patient	Used for established patients with a problem-focused visit of lower complexity than required for `99241`.
`99242`	Office or other outpatient consultation for a new or established patient	Higher-level consultation code (moderate complexity) closely related; use when history/exam/MDM exceed `99241` requirements.
`99354`	Prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service	Use when face-to-face time for the consult extends beyond the usual ~15 minutes and prolonged services are documented.

Related Modifiers

8 rows

Modifier	Description	When to Use
22	Modifier –22 (Increased Procedural Services) is used when a reported procedure is substantially more extensive than normally required. The CPT Manual and CMS state it may be appended only when the…	- When to use: Append modifier -22 to a procedural CPT code when the service performed is substantially more extensive than the usual service described by that code — i.e., the procedure required…
23	Modifier -23 (Unusual Anesthesia) is used on anesthesia service CPT codes when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia…	- Use modifier -23 only on anesthesia CPT codes (00100–01999) when a procedure that normally requires no anesthesia or only local anesthesia must be performed under general anesthesia because of…
52	Modifier ‑52 (Reduced Services) indicates that a service or procedure was partially reduced or omitted at the provider’s discretion, allowing reporting of the basic procedure number with a qualifier…	- Use modifier -52 when a physician or qualified health professional electively reduces or omits part of a procedure or service (for example, performing fewer required views or omitting a portion of…
53	Modifier 53 (Discontinued Procedure) signals that a surgical or diagnostic service was begun by the physician but terminated because of extenuating circumstances that threatened the patient’s…	- Use modifier -53 when a physician/qualified healthcare professional has started a surgical or diagnostic procedure (e.g., anesthesia administered, incision or scope insertion) and then discontinues…
54	Modifier ‑54 (“Surgical care only”) is appended to a CPT surgical procedure when the reporting surgeon performs the intraoperative (surgical) component but does not furnish the preoperative and/or…	- Use modifier -54 when the reporting surgeon provided only the intraoperative (surgical) component of a procedure and preoperative and/or postoperative management has been or will be provided by…
55	Modifier –55 indicates the billing provider furnished only postoperative management for a procedure that has a global surgical period. According to AAPC, this modifier is appended to the same CPT…	- Use modifier -55 when billing the same CPT surgical code that has a 10- or 90-day global period and you, as a provider other than the original surgeon, furnished ONLY postoperative management (no…
56	Modifier ‑56 indicates the reporting provider furnished only the preoperative management for a surgical procedure and did not perform the intraoperative or postoperative care. It is used in…	- Use Modifier -56 when a provider performs only the preoperative management in a split‑care situation (one physician manages preop care while a different physician performs the intraoperative…
62	Modifier 62 indicates that two surgeons function as co‑surgeons, each performing distinct parts of the same primary surgical procedure. It is appended to the primary procedure code (and any…	- Use modifier -62 when two surgeons act as co‑surgeons (both primary surgeons) on a single definitive primary procedure, each performing distinct parts of the same surgical procedure (append -62 to…

Related Provider Taxonomies

8 rows

Taxonomy Code	Specialty	Notes
207Q00000X	Family Medicine Physician	Family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadt…
207R00000X	Internal Medicine Physician	A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults…
208D00000X	General Practice Physician	A physician who specializes in the general practice of diagnosing, treating, and managing patients with a variety of illnesses and conditions.
2080P0207X	Pediatric Hematology & Oncology Physician	A pediatrician trained in the combination of pediatrics, hematology and oncology to recognize and manage pediatric blood disorders and cancerous disea…
3418M1130X	Military or U.S. Coast Guard Water Transport Ambulance	Vehicle and staff for patient emergency or non-emergency sea/water transport
2080B0002X	Pediatric Obesity Medicine Physician	A physician who specializes in the treatment of obesity demonstrates competency in and a thorough understanding of the treatment of obesity and the ge…
207VX0000X	Obstetrics Physician	A physician who specializes in diagnosis, treatment, and management of patients with obstetric conditions.
2084H0002X	Hospice and Palliative Medicine (Psychiatry & Neurology) Physician	A psychiatrist or neurologist with special knowledge and skills to prevent and relieve the suffering experienced by patients with life-limiting illnes…

Related ICD-10-CM Codes

5 rows

ICD-10-CM Code	Description
Z01.419	Encounter for gynecological examination (general) (routine) without abnormal findings
R05
R53.83	Other fatigue
Z00.00	Encounter for general adult medical examination without abnormal findings
R10.9	Unspecified abdominal pain

Frequently Asked Questions

References

1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.

Published by

Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.

CPT 99241: Office Consultation, Problem-Focused Visit

Sign up for cpt 99241 policy alerts

National Reimbursement Benchmarks

CPT 99241: Office Consultation, Problem-Focused Visit

Sign up for cpt 99241 policy alerts

National Reimbursement Benchmarks

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

What clinical elements define CPT 99241 and how long is a typical visit?

What do the reimbursement benchmarks show for CPT 99241 across major payers?

Which modifiers are commonly associated with 99241 and when are they used?

What related CPT codes should be considered when coding visits similar to 99241?

What documentation elements are expected for a visit billed as 99241?

References

Clinical & Coding Specifications

Clinical Context

Related CPT Codes

Related Modifiers

Related Provider Taxonomies

Related ICD-10-CM Codes

What clinical elements define CPT 99241 and how long is a typical visit?

What do the reimbursement benchmarks show for CPT 99241 across major payers?

Which modifiers are commonly associated with 99241 and when are they used?

What related CPT codes should be considered when coding visits similar to 99241?

What documentation elements are expected for a visit billed as 99241?

References