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See a sample rate comparisonCPT 42821 Fee Schedule
Last Verified: October 2026
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.
T&A Age 12 And Over
| 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 | SG - Scene to Hospital ESRD facility AG - Primary physician |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $272.22 national non-facility rate (2026) · View Medicare rates for 42821 |
| Medicaid Fee Schedule | $228.735 median of the 8 states in the free preview · View Medicaid rates for 42821 |
National average reimbursement for CPT 42821 by major payers:
$381.51
$407.63
$445.00
$501.10
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CPT 42821
5 of 25 sample ratesHigher to lower in this preview
Texas Health Harris Methodist Hospital Stephenville
$4,781.00Published rateWilmington Asc LLC, Wilmington Health Ambulatory Surgery Center
$1,680.00Published rateMurrieta Specialty Surgery Center PC A Professional Corporation
$1,130.00Published rateUpnt Surgery LLC
$680.00Published rateJennifer Sitzman
Deaconess Hospital Inc
$243.24Published rate
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See a sample payer proposalCPT 42821 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42821 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 42821 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 42821. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42821 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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