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See a sample rate comparisonCPT 42831 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.
Adenoidectomy Primary 12 & 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 | 51 - Multiple procedures SG - Scene to Hospital ESRD facility |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $212.76 national non-facility rate (2026) · View Medicare rates for 42831 |
| Medicaid Fee Schedule | $172.615 median of the 8 states in the free preview · View Medicaid rates for 42831 |
National average reimbursement for CPT 42831 by major payers:
$297.08
$300.61
$332.30
$376.57
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CPT 42831
5 of 25 sample ratesHigher to lower in this preview
Litchfield Hills Surgery Center
$4,617.00Published rateLakeland Regional Health Surgery Center, LLC
$1,446.00Published rateWestern Washington Endoscopy Centers, LLC
Western Washington Endoscopy Centers LLC
$986.00Published rateTourney Plaza Surgical Center
$588.00Published rateMell Welborn
Deaconess Hospital Inc
$394.38Published rate
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See a sample payer proposalCPT 42831 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42831 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 42831 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 42831. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42831 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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