CPT 99191: Federal IDR outcomes
Assembly and operation of heart-lung machine, 45 minutes
In 2025 Q1–Q4, the provider or facility offer prevailed in 96.6% of 87 determined Federal IDR dispute line items for CPT 99191. The median prevailing offer was 4.16x the QPA (25th–75th percentile 2.58x–4.72x; n = 86). The median time to a decision was 24 business days (n = 87).
Determined line items
87
2025 Q1–Q4 · 1 split decisions excluded
Provider win rate
96.6%
n = 87 · 2025 Q1–Q4
Median payment vs QPA
4.16x
middle half 2.58x–4.72x · n = 86 · 2025 Q1–Q4
Median days to decision
24
business days, from dispute initiation · n = 87 · 2025 Q1–Q4
Dollar amounts
Total awarded
$33,180
sum of prevailing offers · n = 31 · 2025 Q1–Q4
Total QPA
$8,485
sum of QPAs, same line items · n = 31 · 2025 Q1–Q4
Awarded above QPA
$24,695
total awarded minus total QPA · n = 31 · 2025 Q1–Q4
Median award per line item
$1,300
mean $1,070 · n = 31 · 2025 Q1–Q4
Median QPA
$290
per line item · n = 31 · 2025 Q1–Q4
Award vs QPA, dollar-weighted
3.91x
total awarded ÷ total QPA · n = 31 · 2025 Q1–Q4
Dollar amounts come from the separate CMS “QPA and Offers” file: line items decided for the provider or the plan with a non-suppressed QPA and prevailing offer. That file cannot be joined to the line items above, so its n differs. Awarded = the prevailing (selected) offer; it is not a record of what was paid. State comes from the file’s geographic region; a metro area that spans states counts in each. How the dollar figures work
Dollar amounts by period
| Period | Line items with $ | Total awarded | Total QPA | Above QPA | Median award | Median QPA | Award ×QPA ($-weighted) |
|---|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 31 | $33,180 | $8,485 | $24,695 | $1,300 | $290 | 3.91x |
| 2024 Q3–Q4 | Fewer than 30 line items with dollar amounts; not shown. | ||||||
| 2024 Q3–2025 Q4 | 31 | $33,180 | $8,485 | $24,695 | $1,300 | $290 | 3.91x |
| 2023 Q1–2024 Q2 | Not available (see methodology). | ||||||
From the CMS QPA and Offers file (see above). Award ×QPA here is total awarded ÷ total QPA, so large claims weigh more than in the per-line median ratio.
By period
| Period | Line items | Win % | Median ×QPA | 25th–75th | Ratio n | Median days |
|---|---|---|---|---|---|---|
| 2025 Q1–Q4 | 87 | 96.6% | 4.16x | 2.58x–4.72x | 86 | 24 |
| 2024 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–Q4 | Fewer than 30 determined line items; not shown. | |||||
| 2023 Q1–2025 Q4 | 87 | 96.6% | 4.16x | 2.58x–4.72x | 86 | not pooled |
Line items = determined dispute line items (n). Win rate excludes split decisions and includes default decisions. Ratio n = line items reporting a payment-to-QPA ratio. Days are business days as reported by CMS (2023–2024: from IDR entity assignment; 2025: from initiation) and are never pooled.
By state
| State (place of service) | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Texas | 34 | 97.1% | 4.72x | 34 | 24.5 |
| Florida | 32 | 93.8% | 4.36x | 31 | 25 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
By specialty
| Specialty group | Line items | Win % | Median ×QPA | Ratio n | Median days |
|---|---|---|---|---|---|
| Critical care | 82 | 96.3% | 4.16x | 81 | 24 |
2025 Q1–Q4 · rows with n ≥ 30 determined line items · sorted by n.
Section: Medicine (90281–99607, excluding E/M)
FAQ
What is the Federal IDR provider win rate for CPT 99191?
In 2025 Q1–Q4, the provider or facility offer was selected in 96.6% of 87 determined dispute line items for CPT 99191. Split decisions are excluded from the denominator and default decisions are included. Withdrawn, settled and ineligible disputes are not in the CMS data.
How do Federal IDR payments compare with the QPA for CPT 99191?
In 2025 Q1–Q4, the median prevailing offer was 4.16x the qualifying payment amount (QPA), with a 25th to 75th percentile range of 2.58x to 4.72x (n = 86 line items). This uses the CMS field Prevailing Party Offer as % of QPA, where 1.00x equals the QPA.
How long do Federal IDR decisions take for CPT 99191?
In 2025 Q1–Q4, the median was 24 business days (n = 87 line items), using the CMS field Length of Time to Make Determination (from dispute initiation).