CPT 42961 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 • 21 - Inpatient Hospital |
| Common Modifiers | • None • 78 - Return to OR - related procedure • GC - Service performed by resident under supervision |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 42961 |
National average reimbursement for CPT 42961 by major payers:
$532.02
$560.37
$586.65
$700.58
| 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 42961 | ||||||
United | 42961 | $1213.00 | 1104877976 - VICTOR R. MICHALAK, DBA COSMETIC SURGERY & DERMATOLOGY OF ISSAQUAH, INC. | 911521306 | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $2206.00 | 1720325160 - SURGCENTER OF DEER VALLEY, LLC | 461512703 - (AZ) SURGCENTER OF DEER VALLEY LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $533.00 | 1578600979 - HOTCHKISS AND KATZEN AMBULATORY SURGICAL CENTER, METRO AMBULATORY SURGICAL CENTER | 522048920 - (MD) HOTCHKISS AND KATZEN AMBULATORY SURGICAL CENTER | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $645.00 | 1972156842 - NORMAN REGIONAL HOSPITAL AUTHORITY, MEDICAL PLAZA ENDOSCOPY | 736048282 | OK | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1421.00 | 1619370434 - SANDPOINT SURGERY CENTER LLC | 465723093 - (ID) SANDPOINT SURGERY CENTER LLC | ID | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1444.00 | 1437871373 - NORTHEAST INDIANA AMBULATORY SURGERY CENTER LLC | 830979985 - (IN) NORTHEAST INDIANA AMBULATORY SURGERY CENTER LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1380.00 | 1154326650 - SCOTTSDALE SURGICAL PARTNERS LLC, NORTH VALLEY SURGERY CENTER | 201808351 | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1272.00 | 1144607862 - DEKALB SURGICAL SERVICES, LLC | 471088369 - (IL) DEKALB SURGICAL SERVICES LLC | IL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1475.00 | 1679858849 - THE EASTSIDE ENDOSCOPY CENTER, LLC | 911665997 - (WA) THE EASTSIDE ENDOSCOPY CENTER LLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $876.00 | 1992785232 - NORTHWEST FLORIDA A S C LP, NORTHWEST FLORIDA GASTROENTEROLOGY CENTER | 621647401 - (FL) NORTHWEST FLORIDA A S C LP | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1456.00 | 1235105248 - GURLEY SURGERY CENTER, THE GYN CENTER | 621159796 - (TN) GURLEY SURGERY CENTER | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $955.00 | 1811059306 - PENINSULA EYE CENTER, P.A, PENINSULA CATARACT & LASER CENTER | 520974706 - (MD) PENINSULA EYE CENTER PA | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1819.00 | 1588619811 - LAWRENCEVILLE SURGERY CENTER, LLC | 582591488 - (GA) LAWRENCEVILLE SURGERY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1954.00 | 1053971457 - BAPTIST HEALTH SURGERY CENTER LLC, BAPTIST HEALTH SURGERY CENTER AT BETHESDA WEST | 650663357 - (FL) BAPTIST HEALTH SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1350.00 | 1992759930 - IDAHO SURGICENTER INC, IDAHO SURGICENTER SOUTH | 200049792 - (ID) IDAHO SURGICENTER INC | ID | 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 42961 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42961 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 42961 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 |
|---|---|---|
| 42950-CPT | Moderate | Pharyngoplasty |
| 42960-CPT | Moderate | Control Hemorrhage Oropharynx Simp |
| 42961-CPT | Moderate | Control Oropharyngeal Hemorrhage (Primary Or Secondary, Eg, Posttonsillectomy); Complicated, Requiring Hospitalization |
| 42962-CPT | Moderate | Control Oropharyngeal Hemorrhage (Primary Or Secondary, Eg, Posttonsillectomy); With Secondary Surgical Intervention |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 42961. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42961 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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