99221 — Initial hospital care with straightforward or low level of medical decision making, per day, if using time, at least 40 minutes

What the market charges

Across 11,242 negotiated rates, the middle 80% fall between $78 and $209, with a median of $120.

What Medicare pays

Medicare allowed an average of $79 for this code, across 555,578 services billed by 18,351 providers. At the median, the market charges 1.5 times what Medicare pays for this code.

Where this is billed, and what it costs there

The states billing 99221 most, by Medicare service volume, each compared against the national average of $79. Each links to the providers Mishe lists there.

• New York — 1,455 providers billed it, Medicare allowed $88 — 11% above the national average
• Florida — 1,584 providers billed it, Medicare allowed $81 — 3% above the national average
• Pennsylvania — 1,389 providers billed it, Medicare allowed $78 — 1% below the national average
• Texas — 999 providers billed it, Medicare allowed $78 — 1% below the national average
• California — 986 providers billed it, Medicare allowed $84 — 6% above the national average
• Ohio — 1,018 providers billed it, Medicare allowed $75 — 5% below the national average
• Illinois — 920 providers billed it, Medicare allowed $81 — 3% above the national average
• New Jersey — 680 providers billed it, Medicare allowed $83 — 5% above the national average

Claim-editing rules

These are National Correct Coding Initiative procedure-to-procedure edits — the rules a payer applies when deciding whether two codes billed together are both payable.

Codes this one absorbs

Billed together, 99221 is the payable code and these are not separately payable. 4 pairs in total.

• 51721 — a modifier may allow both to be paid
• 96380 — a modifier may allow both to be paid
• 96381 — a modifier may allow both to be paid
• 0655T — a modifier may allow both to be paid

Codes that absorb this one

Billed alongside any of these, 99221 is not separately payable. 250 pairs in total.

• 15011 — a modifier may allow both to be paid
• 15013 — a modifier may allow both to be paid
• 15015 — a modifier may allow both to be paid
• 15017 — a modifier may allow both to be paid
• 15778 — a modifier may allow both to be paid
• 15853 — a modifier may allow both to be paid
• 15854 — a modifier may allow both to be paid
• 22860 — a modifier may allow both to be paid
• 25448 — a modifier may allow both to be paid
• 30468 — a modifier may allow both to be paid
• 30469 — a modifier may allow both to be paid
• 32408 — a modifier may allow both to be paid

Other codes

• 99214 — Established patient office or other outpatient visit with moderate level of decision making, if using time, 30 minutes or more
• 99213 — Established patient office or other outpatient visit with low level od decision making, if using time, 20 minutes or more
• 97530 — Therapy procedure using functional activities
• 99232 — Subsequent hospital care with moderate levelof medical decision making, if using time, at least 35 minutes
• 97112 — Therapy procedure to re-educate brain-to-nerve-to-muscle function, each 15 minutes
• 99233 — Subsequent hospital care with moderate levelof medical decision making, if using time, at least 50 minutes
• 88305 — Pathology examination of tissue using a microscope, intermediate complexity
• 99309 — Subsequent nursing facility care with moderate level of medical decision making, per day, if using time, at least 30 minutes
• 87798 — Detection test by nucleic acid for organism, amplified probe technique
• 98941 — Chiropractic manipulative treatment, 3-4 spinal regions

Deploy this for your team

Every figure on this page came from published payer and Medicare data, assembled by Mishe. The same pricing, claim-editing and care-pathway intelligence runs underneath the plans Mishe operates.

• Contact Mishe to learn how to deploy these resources for your team
• Guides to direct-pay healthcare
• Cash prices by procedure
• Find a provider by state

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