How much does Medicare pay for CPT 99221?

Medicare allowed an average of $78.81 per service and paid $61.39 of that, the balance being the patient's coinsurance and deductible (2024 data). Providers submitted an average of $275.43, which is what they billed rather than what they received — Medicare pays its fee schedule regardless of the charge.

What is CPT code 99221?

Initial hospital care with straightforward or low level of medical decision making, per day, if using time, at least 40 minutes. It was billed 555,578 times to 530,706 Medicare beneficiaries by 18,351 providers in 2024.

Does 99221 pay differently in an office than a hospital?

Yes. The allowed amount averaged $77.13 in an office setting and $78.82 in a facility. The office rate is generally higher because the practice supplies the room, staff and equipment out of that single payment; in a hospital those are billed separately by the facility.

Which specialty bills 99221 most?

Nurse Practitioner, with 88,043 services from 2,519 clinicians. Next are General Surgery, Physician Assistant, Internal Medicine.

CPT 99221

Initial hospital care with straightforward or low level of medical decision making, per day, if using time, at least 40 minutes

$78.81Medicare-allowed amount per service, averaged across 555,578 services

Providers submitted

$275.43

Asking price, not received

Medicare allowed

$78.81

The fee schedule figure

Medicare paid

$61.39

Balance is patient coinsurance

Providers submitted an average of $275.43 for this code and Medicare allowed $78.81 — 3.5× less. That gap is normal and means nothing on its own: Medicare pays its fee schedule regardless of what is billed, so the submitted figure describes a hospital chargemaster, not a price anyone paid. Of the allowed amount Medicare paid $61.39 (78%); the rest is the patient’s coinsurance and deductible.

Office pays differently to hospital

Office / non-facility: $77.13
Hospital / facility: $78.82

The facility rate is higher for this code, which is unusual and generally means the service depends on equipment or staffing a hospital carries. 1,248 services were billed in an office setting and 554,330 in a facility.

Services: 555,578
Beneficiaries: 530,706
Providers billing it: 18,351
Total allowed: $43,785,102

What Medicare pays for CPT 99221

Across 555,578 services billed by 18,351 providers to 530,706 beneficiaries, Medicare allowed an average of $78.81 per service. The allowed amount is the figure that matters: it is what Medicare and the patient together owe, set by the fee schedule and adjusted for local practice costs. What a provider chose to submit has no bearing on it.

Who bills 99221

Specialty	Services	Beneficiaries	Avg allowed	Providers
Nurse Practitioner	88,043	83,738	$68.61	2,519
General Surgery	52,887	51,255	$81.21	2,041
Physician Assistant	45,447	44,112	$69.48	1,748
Internal Medicine	40,746	37,898	$81.77	1,216
Gastroenterology	38,603	37,581	$81.47	1,198
Urology	27,170	26,201	$82.33	981
Cardiology	25,438	24,407	$82.44	821
Orthopedic Surgery	23,656	23,314	$81.03	986
Neurology	18,914	18,389	$82.19	609
Vascular Surgery	16,498	15,748	$83.17	543
Physical Medicine and Rehabilitation	16,372	15,551	$84.42	270
Neurosurgery	16,181	15,914	$81.21	576
Family Practice	14,892	13,479	$78.79	426
Infectious Disease	12,774	11,844	$83.52	299
Podiatry	12,315	11,459	$82.00	383

99221 reimbursement by state

Two different numbers. Allowed is what Medicare actually allowed in that state, which includes the local practice-cost adjustment. Standardized strips that geographic adjustment out of the payment, so it is the column to use when comparing states — a difference there reflects how the code was billed, not what it costs to run a practice locally.

State	Services	Allowed	Standardized pmt	Providers
New York	53,954	$87.97	$60.86	1,456
Florida	53,043	$80.82	$60.39	1,587
Pennsylvania	37,816	$78.06	$60.74	1,393
Texas	32,356	$78.27	$61.06	998
California	28,962	$84.02	$61.66	982
Illinois	28,573	$81.31	$60.21	932
Ohio	28,460	$75.32	$59.39	1,023
New Jersey	25,592	$82.74	$60.26	678
Massachusetts	17,822	$80.63	$59.78	627
Michigan	15,293	$80.85	$61.46	518
Missouri	14,354	$75.90	$60.51	454
Virginia	13,646	$76.11	$59.44	494
Indiana	13,189	$72.39	$59.87	472
Georgia	13,088	$76.37	$59.88	503
Kentucky	12,714	$75.35	$60.22	396
Maryland	11,861	$79.74	$59.65	364
North Carolina	11,105	$75.03	$60.37	458
Tennessee	10,837	$72.70	$59.13	346
South Carolina	10,704	$75.73	$60.42	368
Connecticut	10,477	$80.62	$58.78	372
Wisconsin	8,842	$72.59	$59.87	370
Mississippi	8,117	$72.36	$59.13	192
Arkansas	7,435	$70.25	$59.52	191
Arizona	7,421	$76.94	$60.27	293
Louisiana	6,528	$75.27	$60.64	187
Kansas	6,448	$71.84	$59.06	209
Minnesota	5,566	$74.77	$59.26	271
Iowa	5,354	$71.84	$59.06	204
Alabama	5,159	$73.96	$61.24	180
Delaware	4,989	$76.32	$59.65	140
Oklahoma	4,981	$74.95	$60.63	169
West Virginia	4,406	$77.52	$60.52	160
Nebraska	4,001	$70.96	$59.31	118
Washington	3,917	$76.51	$57.64	148
Nevada	3,785	$75.38	$59.42	116
Oregon	3,031	$76.91	$58.74	107
Colorado	2,541	$77.59	$59.54	130
North Dakota	2,454	$73.95	$58.69	70
Maine	2,273	$74.94	$58.83	90
New Hampshire	2,251	$75.23	$57.97	94
Utah	1,799	$71.69	$57.13	67
South Dakota	1,643	$72.68	$58.83	64
Montana	1,420	$75.58	$58.57	53
Rhode Island	1,343	$78.00	$59.59	50
District of Columbia	981	$86.39	$61.00	31
Hawaii	975	$76.57	$58.78	35
Vermont	956	$77.43	$62.22	45
New Mexico	869	$77.21	$59.01	47
Idaho	688	$71.72	$56.84	31
Wyoming	558	$73.52	$57.72	26
Alaska	440	$102.34	$61.60	22
Puerto Rico	315	$77.12	$63.22	16
ZZ	130	$77.50	$62.49	3
AP	116	$81.59	$61.94	1

Related codes

99214Established patient office or other outpatient visit$117.48
99213Established patient office or other outpatient visit$83.92
99232Subsequent hospital care$76.07
99233Subsequent hospital care$115.58
99215Established patient office or other outpatient visit$163.65
99204New patient office or other outpatient visit$157.90
99223Initial hospital care$167.67
99285Emergency department visit$169.68
99203New patient office or other outpatient visit$104.03
99212Established patient office or other outpatient visit$52.42
99291Critical care$208.35
99222Initial hospital care$126.29

Billing this code is not the same as earning it

An allowed amount is revenue to a practice, not income to a clinician. It funds staff, premises, equipment and supplies before anyone is paid. What clinicians actually earn is published separately by the Department of Labor, and what industry pays them is published separately again by CMS — this site carries both.

What doctors are paid →·Look up a clinician →·All procedure codes →

Where this comes from. CMS Medicare Physician & Other Practitioners, by Provider and Service, 2024. It covers fee-for-service Original Medicare Part B only — not Medicare Advantage, not Medicaid, and not commercial insurance, which typically pays more for the same code.

How it is averaged. CMS publishes one average per provider per code. Every figure here is re-weighted by the number of services, so a clinician who billed the code 4,000 times counts 4,000 times more than one who billed it twice. CMS also suppresses any provider-code pair with fewer than 11 beneficiaries, so low-volume practice is missing from these totals by design.