CPT 99242: Office or Outpatient Consultation, Straightforward/20 min
Commercial payers pay $91 on average nationally for this procedure.
CPT code 99242 describes an office or other outpatient consultation for evaluation and management where the visit involves straightforward medical decision making or the clinician spends at least 20 minutes of total time on the single-date encounter; typical service type is an E/M consultation provided in an office or outpatient clinic setting and the description is used for billing and documentation to reflect the level of clinician evaluation and time-based care delivered.
For related coverage guidance, see recent payer policy updates: Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA), Cardiovascular Disease Risk Assessment, Biomarkers for Myocardial Infarction and Chronic Heart Failure.
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National Reimbursement Benchmarks
National commercial reimbursement for CPT 99242 centers around BUCA’s average commercial benchmark of $90.90, with individual payers showing meaningful spread. UnitedHealth Group posts the highest central tendency at a median of $108.90 and a mean of $120.80, while Cigna and Blue Cross Blue Shield sit nearer BUCA with medians of $88.70 and $75.90 respectively; Aetna’s median is lower at $67.10. These figures indicate a market where mid-to-high commercial rates cluster around $70–$120, with BUCA as a useful average commercial reference point at $90.90.
Dispersion measured by the interquartile spread (P75 minus P25) highlights variation: Aetna’s IQR is $59.00 ($105.00 - $46.90) and Blue Cross Blue Shield’s IQR is $36.00 ($98.40 - $62.80), while Cigna’s IQR is $58.70 ($122.10 - $64.40), BUCA’s IQR is $50.80 ($111.90 - $63.80), and UnitedHealth Group’s IQR is $65.60 ($149.40 - $82.40). UnitedHealth Group therefore shows the widest mid-market dispersion at $65.60 and Blue Cross Blue Shield the tightest at $36.00.