CPT 42509 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address high-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 |
| Complexity Level | High |
| CMS | $796.37 Physician Fee Schedule |
National average reimbursement for CPT 42509 by major payers:
$1,077.12
$1,123.05
$1,147.48
$1,384.22
| 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 42509 | ||||||
United | 42509 | $2294.00 | 1295088292 - CADENCE AMBULATORY SURGERY CENTER, LLC | 800838376 | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $4561.00 | 1174165237 - RIVER RIDGE SURGICAL SUITES, LLC | 833741084 - (IN) RIVER RIDGE SURGICAL SUITES LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $3792.00 | 1881659613 - WEST HILLS SURGICAL CENTER LTD | 621625014 - (CA) WEST HILLS SURGICAL CENTER LTD | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $5433.00 | 1841316841 - PACIFIC ENDOSCOPY CENTER, LLC | 203905706 - (HI) PACIFIC ENDOSCOPY CENTER, LLC | HI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $3767.00 | 1871608216 - COVENANT HIGH PLAINS SURGERY CENTER, LLC, COVENANT HIGH PLAINS SURGERY CENTER - 22ND STREET | 752177401 - (TX) COVENANT HIGH PLAINS SURGERY CENTER LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $1608.00 | 1073601332 - LISA RENFRO SURGERY CENTER LLC | 43612312 - (MD) LISA RENFRO SURGERY CENTER LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $1471.09 | 1114159514 - BILAL HIJAZI | 350593390 - DEACONESS HOSPITAL INC | TN | Emergency Medicine Physician (207P00000X) |
United | 42509 | $4481.91 | 1649748708 - ANKENY MEDICAL PARK SURGERY CENTER LC | 831281114 - (IA) ANKENY MEDICAL PARK SURGERY CENTER LC | IA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $2445.00 | 1689633588 - SOUTH JERSEY ENDOSCOPY LLC, DIMARINO-KROOP-PRIETO GI ASSOC | 200478348 - (NJ) SOUTH JERSEY ENDOSCOPY LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $9761.00 | 1396342838 - LEXINGTON HEALTH INC, LMC IRMO ASC | 852276567 - LEXINGTON HEALTH INC | SC | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $2300.00 | 1952834277 - AMERICAN ACCESS CARE OF TOWSON ASC LLC | 814571016 - (MD) AMERICAN ACCESS CARE OF TOWSON ASC LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $2552.00 | 1245297662 - WOODLAND SURGERY CENTER LLC | 391998961 - (WI) WOODLAND SURGERY CENTER, LLC | WI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $5249.00 | 1962788059 - SURGCENTER OF SILVER SPRING, LLC | 452950933 - (MD) SURGCENTER OF SILVER SPRING LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $2200.00 | 1669474748 - ARC KENTUCKY LLC, DUPONT SURGERY CENTER | 621754364 - (KY) ARC KENTUCKY LLC | KY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42509 | $2236.00 | 1629045133 - MONTICELLO COMMUNITY SURGERY CENTER, LLC, UVA HEALTH SURGICAL CARE RIVERSIDE | 113656095 - (VA) MONTICELLO COMMUNITY SURGERY | VA | 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 42509 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42509 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 42509 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 |
|---|---|---|
| 42420-CPT | High | Excis Parotid Tumor/Gland;All W Dissec/P |
| 42500-CPT | Moderate | Sialodochoplasty Primary/Simple |
| 42505-CPT | Moderate | Sialodochoplasty Second/Complic |
| 42509-CPT | High | Creation Of New Drainage Tracts Of Major Saliva Gland Ducts On Both Sides Of Mouth With Removal Of Salivary Glands Below Both Sides Of Jaw |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42509. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42509 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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