CPT 42960 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 | • 22 - On Campus Outpatient Hospital • 11 - Office |
| Common Modifiers | • None • 78 - Return to OR - related procedure • 58 - Staged or related procedure during postoperative period |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 42960 |
National average reimbursement for CPT 42960 by major payers:
$216.02
$224.06
$233.98
$273.84
| 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 42960 | ||||||
United | 42960 | $643.00 | 1003103474 - NEW ALBANY SURGERY CENTER, LLC | 451617821 - (OH) NEW ALBANY SURGERY CENTER, LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $152.00 | 1255309803 - G S S C LTD PARTNERSHIP | 680343818 - (CA) GSSC LTD PARTNERSHIP DBA GREATER SACRAMENTO SURGERY CENTER | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $531.00 | 1215548524 - SUMMIT AMBULATORY SURGICAL CENTER, LLC | 522148280 | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $250.00 | 1457460248 - OSC LLC, OMAHA SURGICAL CENER | 470693440 - (NE) OSC LLC | NE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $245.00 | 1215919113 - VISION INSTITUTE OF MICHIGAN SURGERY CENTER PC, SURGERY CENTER OF MICHIGAN | 382945641 | MI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $296.00 | 1376536482 - BEND SURGERY CENTER LLC, BEND SURGERY CENTER | 911772048 - (OR) BEND SURGERY CENTER, LLC | OR | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $304.00 | 1083384432 - NASHVILLE SURGICENTER, LLC | 474086590 - (TN) NASHVILLE SURGICENTER LLC | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $120.00 | 1184894693 - LA/OC SURGICAL CENTER, INC. | 262108942 - (CA) LAOC SURGICAL CENTER INC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $544.00 | 1023071180 - SAHARA OUTPATIENT SURGERY CENTER LTD | 752509486 - (NV) SAHARA OUTPATIENT SURGERY CENTER LTD | NV | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $295.82 | 1861411100 - WILLIAM TORTORIELLO | 350593390 - DEACONESS HOSPITAL INC | IN | Family Medicine Physician (207Q00000X) |
United | 42960 | $125.00 | 1114057023 - CROSSROADS SURGERY CENTER INC | 205799348 - (MN) CROSSROADS SURGERY CENTER INC | MN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $555.00 | 1770929044 - SURGCENTER OF PALM BEACH GARDENS, SURGCENTER OF PALM BEACH GARDENS, LLC | 462315994 - (FL) SURGCENTER OF PALM BEACH GARDENS, LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $1250.00 | 1023159860 - THOUSAND OAKS SURGERY CENTER, LLC | 272867027 - (CA) THOUSAND OAKS SURGERY CENTER LLC | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $574.00 | 1972092146 - SURGERY CENTRE OF SW FLORIDA LLC, FORT MYERS SURGERY CENTER | 454068750 | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42960 | $39.00 | 1871718270 - PRINCE GEORGES MULTI SPECIALTY SURGERY CENTER | 521842302 - (MD) PRINCE GEORGES MULTI SPECIALTY SURGERY CENTER | MD | 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 42960 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42960 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 42960 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 |
|---|---|---|
| 42860-CPT | Moderate | Exc Tonsil Tags |
| 42960-CPT | Moderate | Control Hemorrhage Oropharynx Simp |
| 42961-CPT | Moderate | Control Oropharyngeal Hemorrhage (Primary Or Secondary, Eg, Posttonsillectomy); Complicated, Requiring Hospitalization |
| 42971-CPT | Moderate | Control Of Nasopharyngeal Hemorrhage (Primary Or Secondary, Eg, Postadenoidectomy); Complicated, Requiring Hospitalization |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42960. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42960 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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