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See a sample rate comparisonCPT 42960 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.
Control Oropharyngeal Hemorrha, Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg Posttonsillectomy) Simple Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg
| 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 | 78 - Return to OR - related procedure 58 - Staged or related procedure during postoperative period |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $145.63 national non-facility rate (2026) · View Medicare rates for 42960 |
| Medicaid Fee Schedule | $117.265 median of the 8 states in the free preview · View Medicaid rates for 42960 |
National average reimbursement for CPT 42960 by major payers:
$216.02
$224.06
$233.98
$269.79
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CPT 42960
5 of 25 sample ratesHigher to lower in this preview
Glastonbury Surgery Center, LLC
$1,543.00Published rateSurgcenter Tucson, LLC
$555.00Published rateNashville Surgicenter, LLC
Nashville Surgicenter LLC
$304.00Published rateSurgcenter Of Greenbelt, LLC
Surgcenter Of Greenbelt LLC
$174.00Published ratePrince Georges Multi Specialty Surgery Center
$39.00Published rate
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See a sample payer proposalCPT 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 Oropharyngeal Hemorrha, Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg Posttonsillectomy) Simple Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg |
| 42961-CPT | Moderate | Control Oropharyngeal Hemorrha, Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg Posttonsillectomy) Complicated Requiring Hospitalization Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg |
| 42971-CPT | Moderate | Control Nose Throat Bleeding, 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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