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 |
| CMS | $411.77 Physician Fee Schedule |
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 | $1810.00 | 1174873780 - YORKVILLE ENDOSCOPY, LLC | 460857425 - (NY) YORKVILLE ENDOSCOPY LLC | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1114.00 | 1689860124 - PINE GROVE AMBULATORY SURGICAL | 203237578 - (PA) PINE GROVE AMBULATORY SURGICAL | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1213.00 | 1104877976 - VICTOR R. MICHALAK, DBA COSMETIC SURGERY & DERMATOLOGY OF ISSAQUAH, INC. | 911521306 | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $2564.00 | 1245635093 - PARK RIDGE SURGERY CENTER, LLC | 464468691 - (CO) PARK RIDGE SURGERY CENTER LLC | CO | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1250.00 | 1619971470 - ARIZONA ADVANCED SURGERY CENTER, LLC | 202770438 - (AZ) ARIZONA ADVANCED SURGERY CENTER LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1175.00 | 1669437109 - MARIETTA OUTPATIENT SURGERY, LTD | 752160466 - (GA) MARIETTA OUTPATIENT SURGERY LTD | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $2000.00 | 1851848253 - PINNACLE SURGERY CENTER OF AUSTIN | 813117589 - (TX) PINNACLE SURGERY CENTER OF AUSTIN LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1624.00 | 1033181862 - EL PASO ASC LP, ENDOSCOPY CENTER OF EL PASO | 621731682 - (TX) EL PASO ASC LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $2388.00 | 1972886190 - SUMMIT AMBULATORY SURGICAL CENTER, LLC | 522148280 | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $5401.00 | 1740236454 - PRINCESS ANNE AMBULATORY SURGERY MANAGEMENT LLC, PRINCESS ANNE AMBULATORY SURGERY CENTER | 204920880 - (VA) PRINCESS ANNE AMBULATORY SURGERY MANAGEMENT, LLC | VA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1159.00 | 1306249453 - MARK FROMER, LLC, EYE SURGERY CENTERS OF NEW YORK | 274212773 - (NY) MARK FROMER LLC | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $1530.00 | 1609965961 - BROOKINGS AMBULATORY SURGERY CENTER, LLP | 203272258 - (SD) BROOKINGS AMBULATORY SURGERY CENTER LLP | SD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42961 | $950.00 | 1316970916 - SURGICAL SPECIALTY CENTER, LLC | 721418824 - (LA) SURGICAL SPECIALTY CENTER LLC | LA | 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 | $1421.00 | 1619370434 - SANDPOINT SURGERY CENTER LLC | 465723093 - (ID) SANDPOINT SURGERY CENTER LLC | 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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