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 |
| Medicare Fee Schedule | View Medicare rates for 42972 |
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 | $2169.00 | 1578741849 - SCOTT AND WHITE HOSPITAL, BAYLOR SCOTT & WHITE MEDICAL CENTER - TAYLOR | 741595711 - (TX) SCOTT & WHITE HOSPITAL-TAYLOR | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1258.00 | 1366449571 - SHORE OUTPATIENT SURGICENTER LLC | 582252127 - (NJ) SHORE OUTPATIENT SURGICENTER LLC | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1276.00 | 1992423719 - ENDOSCOPY ASC OF MIDDLE GEORGIA LLC | 883065469 | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $939.00 | 1679728901 - ESSEX SPECIALIZED SURGICAL INSTITUTE LLC | 263777820 - (NJ) ESSEX SPECIALIZED SURGICAL INSTITUTE LLC | NJ | 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 | $725.00 | 1790269462 - BARBOUR ORTHOPAEDICS SURGERY CENTER, LLC | 822423698 - (GA) BARBOUR ORTHOPAEDICS SURGERY CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $700.00 | 1649250218 - LORAIN SURGERY CENTER, LLC | 201641777 - (OH) LORAIN SURGERY CENTER LLC | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1233.00 | 1295923670 - SUMMIT AMBULATORY SURGICAL CENTER, LLC | 522148280 | MD | 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 | $520.00 | 1609930676 - BAYWOOD MEDICAL ASSOCIATES, PLLC, DESERT PAIN INSTITUTE - ASC | 861006533 - (AZ) BAYWOOD MEDICAL ASSOCIATES, PLLC DBA DESERT PAIN INSTITUTE | AZ | 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 | $500.00 | 1922262278 - EPS SURGICAL CENTER, LLC | 260875908 - (GA) EPS SURGICAL CENTER LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $993.00 | 1316379647 - MINNESOTA EYE LASER & SURGERY CENTERS, LLC, MINNESOTA EYE LASER & SURGERY CENTERS | 460505033 - (MN) MINNESOTA EYE LASER SURGERY CENTERS LLC | MN | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $1200.00 | 1740231489 - STONEGATE SURGERY CENTER LP | 201211544 - (TX) STONEGATE SURGERY CENTER LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 42972 | $434.00 | 1821250176 - NORTHSHORE AMBULATORY SURGERY CENTER LLC | 800352092 - (LA) NORTHSHORE AMBULATORY SURGERY CENTER LLC | LA | 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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