CPT 42220 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address moderate-level medical decision-making, often including multiple diagnoses or prescription management.
| Key Fact | Detail |
|---|---|
| Service Type | • Surgery • Surgical Procedures on the Digestive System |
| Common Place of Service | • 22 - On Campus Outpatient Hospital • 21 - Inpatient Hospital |
| Common Modifiers | • None • GC - Service performed by resident under supervision • 51 - Multiple procedures |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 42220 |
National average reimbursement for CPT 42220 by major payers:
$731.23
$762.76
$821.26
$951.58
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
Select a payer to view fee schedule data Choose a payer from the options above to see rates for CPT 42220 | ||||||
United | 42220 | $1286.00 | 1255446910 - DOWNTOWN BALTIMORE SURGERY CENTER, LLC | 522219532 - (MD) DOWNTOWN BALTIMORE SURGERY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $6506.00 | 1245711803 - SURGCENTER CLEARWATER, LLC, SURGCENTER DUNEDIN | 823682684 - (FL) SURGCENTER CLEARWATER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $8238.00 | 1023316197 - NORTH DALLAS SURGICAL CENTER,LLC, TEXAS HEALTH SURGERY CENTER ADDISON | 272248103 - (TX) NORTH DALLAS SURGICAL CENTERLLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3421.00 | 1639498579 - INTERVENTIONAL SPINE CENTER, LLC | 263161503 - (CA) INTERVENTIONAL SPINE CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3200.00 | 1730601865 - SNAPFINGER VASCULAR ACCESS CENTER ASC LLC | 821940644 - (GA) SNAPFINGER VASCULAR ACCESS CENTER ASC LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3490.00 | 1073039657 - UNIVERSITY ORTHOPEDICS, INC., UOI-EAST BAY SURGERY CENTER | 873506992 | RI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $1100.00 | 1013341734 - CENTER FOR PAIN AND SPINE, LLC | 814348805 | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $11291.00 | 1306163431 - ROC SURGERY LLC, RILEY OUTPATIENT SURGERY CENTER | 271497960 - (IN) ROC SURGERY LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3730.00 | 1528104080 - SURGICAL CENTER AT CEDAR KNOLLS LLC | 202158771 - (NJ) SURGICAL CENTER AT CEDAR KNOLLS | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $5249.00 | 1104181247 - ADVANCED SURGERY CENTER OF NORTHERN LOUISIANA LLC | 455502071 - (LA) ADVANCED SURGERY CENTER OF NORTHERN LOUISIANA, LLC | LA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3259.00 | 1902043284 - AESTHETIC & GENERAL DERMATOLOGY OF SEATTLE | 911886576 - (WA) ELIE LEVY, M.D., P.C. DBA AESTHETIC & GENERAL DERMATOLOGY OF SEATTLE | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $4757.00 | 1306833009 - SOUTH BROWARD ENDOSCOPY L L C | 113685842 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $7012.00 | 1477516979 - FAIRFAX SURGICAL CENTER, L.P. | 621861640 - (VA) FAIRFAX SURGICAL CENTER LP | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $3486.00 | 1770513855 - CAPITAL ENDOSCOPY LLC | 134244093 - (MD) CAPITAL ENDOSCOPY & SURGERY CENTER | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42220 | $2750.00 | 1336510486 - SACRAMENTO HEART AMBULATORY SURGERY CENTER, INC | 475284840 - (CA) SACRAMENTO HEART AMBULATORY SURGERY CENTER INC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
United | 99202 | $100.00 | 1234567890 | 1234567890 | CA | Cardiologist |
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CPT 42220 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42220 code is part of the Surgery services used for Surgical Procedures on the Digestive System. It represents a moderate-complexity encounter and is one of several codes that vary based on time spent, level of medical decision-making, and documentation requirements.
The CPT 42220 code involves more provider time and moderate medical decision-making, unlike lower-level codes that require less time and simpler assessments. It typically includes multiple diagnoses, medication management, or test interpretation, leading to higher reimbursement and more detailed documentation requirements.
| Code | Complexity | Description |
|---|---|---|
| 42182-CPT | Moderate | Repair Lac Palate > 2cmor Complex |
| 42200-CPT | High | Palatoplasty For Cleft Palate Soft A/O H |
| 42210-CPT | High | Palatoplasty For Cleft Palate, With Closure Of Alveolar Ridge; With Bone Graft To Alveolar Ridge (Includes Obtaining Graft) |
| 42220-CPT | Moderate | Palatoplasty Cleft Palate;2ndary Lengthe |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42220. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42220 fee schedule helps patients estimate costs and providers optimize billing for accurate reimbursements.
Factors that affect fee schedules
Medicare & Medicaid Rates
Government-set reimbursement amounts
Private Insurance Rates
Negotiated rates between providers and insurance companies
Geographic Location
Costs may be higher in urban areas.
Provider Type
Hospital providers may have different rates than private practice.
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