CPT 42820 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 | • 24 - Ambulatory Surgical Center • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • SG - Scene to Hospital ESRD facility • AG - Primary physician |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 42820 |
National average reimbursement for CPT 42820 by major payers:
$365.72
$389.65
$426.23
$489.84
| 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 42820 | ||||||
United | 42820 | $740.57 | 1619538683 - GABRIELLA ROMERO | 320261234 | WA | Allergy & Immunology Physician (207K00000X) |
United | 42820 | $976.96 | 1730157611 - JOSEPH MARQUEZ | 910369070 - (WA) THE POLYCLINIC, PLLC | WA | Urology Physician (208800000X) |
United | 42820 | $2104.00 | 1982149761 - THE POLYCLINIC, THE POLYCLINIC MOHS SURGERY | 910369070 - (WA) THE POLYCLINIC, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $671.86 | 1912351289 - ALEX TAMPIO | 911939739 - FRANCISCAN MEDICAL GROUP | WA | Otolaryngology Physician (207Y00000X) |
United | 42820 | $371.70 | 1457788275 - IDEAL OPTION, PLLC | 455513274 - IDEAL OPTION, PLLC | WA | Multi-Specialty Clinic/Center (261QM1300X) |
United | 42820 | $2000.00 | 1053481960 - AESTHETIC ASSOCIATES INC P S, SEATTLE FACIAL PLASTIC SURGERY CENTER | 911650765 - (WA) AESTHETIC ASSOCIATES INC PS | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $446.04 | 1407888910 - BRIAN FONG | 911602128 - (WA) WESTERN WASHINGTON MEDICAL GROUP, INC., P.S. | WA | Urology Physician (208800000X) |
United | 42820 | $610.83 | 1417984956 - STEPHEN TILLES | 911220843 - ASSOCIATION OF UNIVERSITY PHYSICIANS | WA | Allergy & Immunology Physician (207K00000X) |
United | 42820 | $462.55 | 1720246267 - KRIPA KAVASSERI | 273331851 - (WA) WASHINGTON UROLOGY ASSOCIATES, PLLC | WA | Urology Physician (208800000X) |
United | 42820 | $667.73 | 1013186121 - PROLIANCE SURGEONS, INC., P.S., PROLIANCE SURGEONS BELLEVUE ENT AND LAKE WA FACIAL PLASTIC SURGERY | 911606533 - (WA) PROLIANCE SURGEONS, INC., P.S. | WA | Multi-Specialty Group (193200000X) |
United | 42820 | $820.14 | 1457305401 - SETH SCHWARTZ | 910565539 - (WA) VIRGINIA MASON MEDICAL CENTER | WA | Plastic Surgery within the Head & Neck (Otolaryngology) Physician (207YX0007X) |
United | 42820 | $395.10 | 1588611552 - YARROW BAY PLASTIC SURGERY, PLLC, LIEBERTZ PLASTIC SURGERY AT YARROW BAY | 43846267 | WA | Multi-Specialty Group (193200000X) |
United | 42820 | $707.04 | 1346289428 - PROLIANCE SURGEONS, INC., P.S., PROLIANCE SURGEONS SEATTLE ORTHOPEDIC CENTER-ASC | 911606533 - (WA) PROLIANCE SURGEONS, INC., P.S. | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $657.75 | 1760479281 - DENNIS GASKILL | 476620487 - (WA) YAKIMA UROLOGY AT MEMORIAL TR | WA | Urology Physician (208800000X) |
United | 42820 | $674.84 | 1699926402 - PROVIDENCE HEALTH & SERVICES, PROVIDENCE ST MARY MED CTR ER | 300502262 | WA | Multi-Specialty Group (193200000X) |
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 42820 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42820 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 42820 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.
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42820. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42820 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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