CPT 99285 Medicare rate and RVUs

Negotiated rates for 99285 vs Medicare Copy link

Commercial payers' negotiated rates for 99285 have medians of 88% to 129% of Medicare, depending on specialty.

Insurers must publish the rates they negotiate with in-network clinicians (the Transparency in Coverage rule). We reduce each file to medians by county and specialty and set them against Medicare's amount for the same place.

How does your contract compare? Enter your % of Medicare

Payers publish this data, and each dataset carries its month. A negotiated rate describes the contract, not the payment, and networks and plan designs vary. We publish a benchmark only when at least 10 providers from at least 5 separately contracting groups (tax IDs) stand behind it, and no single group accounts for more than 25% of it. Browse all payer benchmarks →

Contracted rate: % of Medicare Copy link

Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for 99285. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $171.35 national baseline; the calculator finds that amount from your service ZIP.

See how to find your contract's actual percentage.

Rates by locality Copy link

The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.

Look up your exact locality →

Q4 2026 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range—its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.

How this amount is computed Copy link

CPT 99285 has a work RVU of 4.00, a non-facility practice expense RVU of 0.65, a facility practice expense RVU of 0.65 and a malpractice RVU of 0.48—for total non-facility RVUs of 5.13 and total facility RVUs of 5.13 in the Q4 2026 release.

The formula is: (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.

Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead—higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, never as zero.

Who’s billing it Copy link

Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link

National Office (non-facility) amounts for the modifiers this code's indicators support. These are single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.

Not payable with 99285: -26/TC (professional/technical split); -50 (bilateral procedure); -62 (co-surgeons, each); -66 (team surgery).

Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment. A row marked If documented carries the ordinary percentage, but this code's CMS indicator allows it only when documentation of medical necessity is submitted. Without that documentation, an unpaid claim is not an underpayment.

CMS RVU26D · October 1 – December 31, 2026 · revision 2 See file rows

Check a pair of codes Copy link

Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit for the pair.

See every current NCCI pair for 99285 →

Based on CMS's National Correct Coding Initiative (NCCI). A few examples appear here; use the complete edit page to check a specific pair.

Modifier 59 and the X modifiers are not a universal bypass—CMS expects the most specific applicable modifier, and which one that is depends on the pair and the documented circumstances.

Check a paired code or view all 742 NCCI pairs →

Medically Unlikely Edit (MUE) limit: 1 unit per patient per date of service.

Payment review for 99285 Copy link

The emergency physician’s visit is only one part of an emergency department bill. Check its PFS amount separately from the hospital facility level, imaging, lab work, and consultants’ claims.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS MLN: Evaluation and Management Services Guide; CMS Medicare Claims Processing Manual (Pub. 100-04).

Rate history by release Copy link

National Office (non-facility) amount for 99285 across quarterly releases. +2.2% increase since Q1 2013 · peak $180.75 in Q1 2021

Why 99285's rate changed Copy link

National baseline (GPCI 1.000) · Office (non-facility) · Before sequestration

99285's national amount rose $3.62 (+2.2%), from $167.73 in Q1 2013 to $171.35 in Q4 2026. Changes to the conversion factor, which CMS sets for every code, took $3.07 off. CMS revaluing 99285 itself added $6.69: +$6.69 from work RVUs, −$6.01 from practice-expense RVUs and +$6.01 from malpractice RVUs. The most recent change came in Q1 2026: +$2.50 (+1.5%), with +$5.51 from the conversion factor, −$4.68 from practice-expense RVUs and +$1.67 from malpractice RVUs.

CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.

How often 99285 is billed Copy link

Across Original Medicare in CY2024, 99285 ranked #15 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars. It repeats: a patient billed for it in 2024 was billed 1.7 times on average that year.

2024 Medicare fee-for-service national totals. They exclude Medicare Advantage, Medicaid and commercial volume, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q4 2026 fee schedule above.

Who bills 99285 to Medicare

Observed CY2024 Medicare fee-for-service billing, by the rendering clinician's CMS specialty. Each share is that specialty's slice of all observed services for this code that year.

Setting split that year: 0% Office (non-facility) · 100% facility. CMS publishes only this facility vs non-facility split, never the exact place of service. The Office (non-facility) figure does not identify urgent care or any other specific setting.

CY2024 Medicare fee-for-service only, from the CMS Physician & Other Practitioners dataset, which suppresses rows under 11 beneficiaries. We omit specialty groups with fewer than 30 observed clinicians, so the shares can fall short of 100%. Specialty and practice-type pages linked elsewhere on this page are curated code lists, not utilization claims.

How 99285 compares with other codes Copy link

Against every code with a national PFS amount in Q4 2026 · National baseline · Before sequestration

45.8% Highest vs. lowest locality

99285's Office amount is 45.8% higher in its highest-paid payment locality than in its lowest. That spread is wider than 59% of the 7,716 codes compared; the median spread is 43.6%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.

+2.2% Since Q1 2013

99285's Office amount rose 2.2% from Q1 2013 to Q4 2026. Over the same period, the median code's amount fell 6.6%. That's higher than the change for 77% of the 6,418 codes priced in both releases.

These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.

Related codes Copy link

Codes near 99285 in the evaluation and management group, with their national Q4 2026 amounts at GPCI 1.000. A dash means the release publishes no payable PFS amount in that setting.

Localis groups these codes for payment research. The grouping isn't the AMA's code families.