CPT 42894 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 | • 21 - Inpatient Hospital • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • GC - Service performed by resident under supervision • 62 - Co-Surgeons |
| Complexity Level | High |
| CMS | $2,285.28 Physician Fee Schedule |
National average reimbursement for CPT 42894 by major payers:
$3,141.37
$3,086.09
$3,352.55
$3,856.94
| 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 42894 | ||||||
United | 42894 | $677.00 | 1588765739 - NORTHWEST ENDOSCOPY CENTER, LLC | 911919202 - (WA) NORTHWEST ENDOSCOPY CENTER LLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $995.00 | 1215381843 - THE REGENTS OF THE UNIVERSITY OF CALIFORNIA, UCLA DEPT OF MEDICINE | 954373071 | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $2011.00 | 1194489757 - WALNUT CREEK SURGICAL SUITES, LLC | 852525715 - (OH) WALNUT CREEK SURGICAL SUITES LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $159.00 | 1770532194 - BROADWEST SPECIALTY SURGICAL CENTER, LLC | 710991736 - (IN) BROADWEST SPECIALTY SURGICAL 401 | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $1348.00 | 1518634732 - MEDSTAR HEALTH ENDOSCOPY CENTER | 872341245 - (MD) MEDSTAR HEALTH ENDOSCOPY CENTER | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $250.00 | 1417937756 - CLEVELAND ASC LLC, CLEVELAND SURGICAL SUITES | 621647411 - (OH) CLEVELAND ASC LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $1007.00 | 1245239656 - SURGERY CENTER OF GILBERT LLC, SURGERY CENTER OF GILBERT | 731596190 - (AZ) SURGERY CENTER OF GILBERT, LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $150.00 | 1396142733 - DIALYSIS ACCESS SERVICES, LLC | 472322456 - (MD) DIALYSIS ACCESS SERVICES LLC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $453.00 | 1295086049 - WOMENS CENTER FOR ADVANCED SURGERY INC | 454798001 - (GA) WOMENS CENTER FOR ADVANCED SURGERY INC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $747.00 | 1871169136 - WICHITA FALLS SPECIALTY ASC LLC, MOMENTUM SPECIALTY SURGERY CENTER | 842950505 - (TX) WICHITA FALLS SPECIALTY ASC LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $1064.00 | 1134262868 - NORTH SHORE SAME DAY SURGERY LLC, NORTH SHORE SURGICAL CENTER | 364120432 - (IL) NORTH SHORE SAME DAY SURGERY LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $100.00 | 1316375884 - OXON HILL UROLOGY SURGERY CENTER PC | 463746777 - (MD) OXON HILL UROLOGY SURGERY CENTER PC | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $1042.00 | 1932164852 - MAY STREET SURGI CENTER, LLC, MAY STREET SURGI CENTER | 223777533 - (NJ) MAY STREET SURGI CENTER, LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $542.00 | 1144970112 - SONORAN ENDOSCOPY CENTER LLC | 852760027 - (AZ) SONORAN ENDOSCOPY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42894 | $978.00 | 1689059222 - GOLDSTEP AMBULATORY SURGERY CENTER, LLC | 465647464 - (NY) GOLDSTEP AMBULATORY SURGERY CENTER LLC | NY | 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 42894 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42894 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 42894 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 |
|---|---|---|
| 42808-CPT | Moderate | Exc./Dest.;Lesion/Pharynx,Any Method |
| 42815-CPT | Moderate | Exc Branchial Cleft Cyst Deep |
| 42892-CPT | High | Resection Of Lateral Pharyngeal Wall Or Pyriform Sinus, Direct Closure By Advancement Of Lateral And Posterior Pharyngeal Walls |
| 42894-CPT | High | Resection Of Pharyngeal Wall Requiring Closure With Myocutaneous Or Fasciocutaneous Flap Or Free Muscle, Skin, Or Fascial Flap With Microvascular Anastomosis |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42894. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42894 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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