CPT 42972 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 • 51 - Multiple procedures |
| Complexity Level | Moderate |
| CMS | $496.84 Physician Fee Schedule |
National average reimbursement for CPT 42972 by major payers:
$651.26
$683.84
$705.21
$848.63
| 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 42972 | ||||||
United | 42972 | $650.00 | 1518149954 - NEUROLOGICAL INSTITUTE AMBULATORY SURGICAL CENTER, LLC | 141983013 - (GA) NEUROLOGICAL INSTITUTE AMBULATORY SURGICAL CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $656.00 | 1447612114 - LPC SURGERY CENTER LLC | 473748606 - (IN) LPC SURGERY CENTER LLC | IN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1938.00 | 1568244192 - TOWER CLOCK SURGERY CENTER APPLETON, LLC | 921425291 - (WI) TOWER CLOCK SURGERY CENTER APPLETON LLC | WI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $650.00 | 1841039443 - PACIFIC GASTRO HEALTH PLLC, PACIFIC GASTRO HEALTH | 201377401 - (WA) PACIFIC GASTROENTEROLOGY, PLLC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1258.00 | 1831525112 - LONGLEAF SURGERY CENTER, LLC | 462421622 - (FL) LONGLEAF SURGERY CENTER LLC | FL | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $711.00 | 1952312399 - ZITELLI & BRODLAND PC, ZITELLI & BRODLAND ASF SOUTH | 251549973 - JOHN A. ZITELLI, MD, PC | PA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1233.00 | 1992713176 - DESERT RIDGE OUTPATIENT SURGERY LLC | 202528902 - (AZ) DESERT RIDGE OUTPATIENT SURGERY LLC | AZ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1123.00 | 1760486369 - MOUNTAIN EMPIRE SURGERY CENTER LP | 621772667 - (TN) MOUNTAIN EMPIRE SURGERY CENTER LP | TN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1749.00 | 1164017778 - MEDICAL CITY SURGERY CENTER OF ALLIANCE, LLC | 822480225 - (TX) MEDICAL CITY SURGERY CENTER OF ALLIANCE LLC | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1192.00 | 1457682841 - PAIN CARE OF NORTH TEXAS | 200081985 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $623.00 | 1316536352 - UROLOGICAL INSTITUTE OF MARYLAND | 352636464 - (MD) UROLOGICAL INSTITUTE OF MARYLAND | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1126.00 | 1700838471 - SANTA CRUZ SURGERY CENTER | 770194916 - (CA) SANTA CRUZ SURGERY CENTER | CA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1249.29 | 1184897472 - LAKE COUNTRY ENDOSCOPY CENTER, LLC | 261572986 - (WI) LAKE COUNTRY ENDOSCOPY CENTER LLC | WI | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $700.00 | 1861029712 - EAST ATLANTA EYE SURGERY CENTER, LLC | 834671737 - (GA) EAST ATLANTA EYE SURGERY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1276.00 | 1801146535 - SURGCENTER AT PARADISE VALLEY, LLC, SURGCENTER AT PIMA CROSSING | 455364868 - (AZ) SURGCENTER AT PARADISE VALLEY | AZ | 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 42972 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 42972 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 42972 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 |
|---|---|---|
| 42804-CPT | Moderate | Biopsy; Nasopharynx Visible Lesion Simpl |
| 42960-CPT | Moderate | Control Hemorrhage Oropharynx Simp |
| 42970-CPT | Moderate | Control Of Nasopharyngeal Hemorrhage, Primary Or Secondary (Eg, Postadenoidectomy); Simple, With Posterior Nasal Packs, With Or Without Anterior Packs And/Or Cautery |
| 42972-CPT | Moderate | Control Of Nasopharyngeal Hemorrhage (Primary Or Secondary, Eg, Postadenoidectomy); 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 42972. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 42972 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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