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See a sample rate comparisonCPT 42961 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) Complicated Requiring Hospitalization 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 21 - Inpatient Hospital |
| Common Modifiers | 78 - Return to OR - related procedure GC - Service performed by resident under supervision |
| Complexity Level | Moderate |
| Medicare Fee Schedule | $372.75 national non-facility rate (2026) · View Medicare rates for 42961 |
| Medicaid Fee Schedule | $301.51 median of the 8 states in the free preview · View Medicaid rates for 42961 |
National average reimbursement for CPT 42961 by major payers:
$532.02
$560.37
$586.65
$686.50
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CPT 42961
5 of 25 sample ratesHigher to lower in this preview
Baylor Surgicare At Plano, LLC, Baylor Scott & White Surgicare - Plano
$3,500.00Published rateLawrenceville Surgery Center, LLC
Lawrenceville Surgery Center LLC
$1,819.00Published rateNortheast Indiana Ambulatory Surgery Center LLC
$1,444.00Published rateSurgeyecare, Inc., Surgeyecare General Partnership
$1,092.00Published rateEagle Physicians And Associates PA, Eagle Endoscopy Center
Eagle Physicians & Associates, P.A.
$500.00Published rate
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See a sample payer proposalCPT 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 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 |
| 42962-CPT | Moderate | Control Oropharyngeal Hemorrha, Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg Posttonsillectomy) With Secondary Surgical Intervention Control Oropharyngeal Hemorrhage Primary Or Secondary (Eg |
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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