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 |
| CMS | $287.56 Physician Fee Schedule |
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 | $404.73 | 1326126897 - NATURAL HEALTH CTR OF MED LAKE PS, CHRISTOPHER WELLWOOD DC PS | 753196807 - (WA) NATURAL HEALTH CTR OF MED LAKE PS | WA | Multi-Specialty Clinic/Center (261QM1300X) |
United | 42820 | $447.14 | 1104811876 - CHARLES STEIGER | 851560720 - (SD) ACUTE CARE SURGERY OF SOUTH DAKOTA PC | WA | Urology Physician (208800000X) |
United | 42820 | $444.54 | 1770550923 - DICK HOISTAD | 911996643 - (WA) SURGICAL ASSOCIATES NORTHWEST, PC | WA | Otolaryngology Physician (207Y00000X) |
United | 42820 | $574.89 | 1780973800 - ARASH FAZL | 910844563 | WA | Multi-Specialty Group (193200000X) |
United | 42820 | $851.65 | 1750520516 - PROVIDENCE HEALTH & SERVICES WA, PMG NW WA GYNECOLOGIC ONCOLOGY ASSOCIATES | 320261234 | WA | Multi-Specialty Group (193200000X) |
United | 42820 | $1400.00 | 1902864879 - SPOKANE SURGERY CENTER LTD PS | 911336886 - (WA) SPOKANE SURGERY CENTER LTD | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
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 | $682.28 | 1982852448 - AMY ANSTEAD | 911606533 - (WA) PROLIANCE SURGEONS, INC., P.S. | WA | Otolaryngology Physician (207Y00000X) |
United | 42820 | $2196.00 | 1083785398 - OLYMPIA ORTHOPAEDIC ASSOCIATES PLLC, OLYMPIA SURGERY CENTER LLC | 911674528 - OLYMPIA ORTHOPAEDIC ASSOCIATES, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $707.04 | 1316109309 - PROLIANCE SURGEONS INC PS, PLASTIC & RECONSTRUCTIVE SURGEONS ASC | 911606533 - (WA) PROLIANCE SURGEONS, INC., P.S. | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $395.10 | 1396123865 - SOUND SURGEONS PLLC, NORTHWEST WEIGHT LOSS SURGERY | 710899232 - (WA) NORTHWEST WEIGHT LOSS SURGERY, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42820 | $520.38 | 1548261308 - NORTHWEST MEDICAL SPECIALTIES PLLC | 911867315 - (WA) NORTHWEST MEDICAL SPECIALTIES, PLLC | WA | Multi-Specialty Clinic/Center (261QM1300X) |
United | 42820 | $500.67 | 1104923119 - SHAWN ROGERS | 910757683 | WA | Otolaryngology Physician (207Y00000X) |
United | 42820 | $964.28 | 1952536906 - JANET LEE | 912073120 | WA | Urology Physician (208800000X) |
United | 42820 | $806.41 | 1629044284 - DAVID ROBINSON | 910565539 - (WA) VIRGINIA MASON MEDICAL CENTER | WA | Allergy & Immunology Physician (207K00000X) |
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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