CPT 43198 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 | • 11 - Office • 22 - On Campus Outpatient Hospital |
| Common Modifiers | • None • GC - Service performed by resident under supervision • 51 - Multiple procedures |
| Complexity Level | Moderate |
| CMS | $207.02 Physician Fee Schedule |
National average reimbursement for CPT 43198 by major payers:
$258.50
$284.09
$300.54
$368.62
| 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 43198 | ||||||
United | 43198 | $386.89 | 1053367276 - ELIZABETH WEAVER | 310667480 - (OH) PROFESSIONAL RADIOLOGY, INC. | OH | Diagnostic Radiology Physician (2085R0202X) |
United | 43198 | $2991.00 | 1376899856 - ST. FRANCIS HOSPITAL, INC., BON SECOURS ST. FRANCIS SURGERY CENTER | 582504530 - (SC) ST FRANCIS HOSPITAL INC | SC | General Acute Care Hospital (282N00000X) |
United | 43198 | $1721.00 | 1407903586 - LUBBOCK HEART HOSPITAL | 510436196 - (TX) LUBBOCK HEART HOSPITAL, LP | TX | General Acute Care Hospital (282N00000X) |
United | 43198 | $292.79 | 1346257870 - TIMOTHY SPIRES | 726000821 | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $451.69 | 1609072792 - KIM POLUDNIANYK | 263757202 | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $192.96 | 1821049743 - DAVID ELIAS | 260458213 - (LA) ORTHOPAEDIC SPORTS SPECIALISTS | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $175.53 | 1750474516 - NORTHWEST TEXAS SURGICAL HOSPITAL, LLC, NORTHWEST TEXAS SURGERY CENTER | 233086987 - (TX) NORTHWEST TEXAS SURGICAL HOSPITAL LLC | TX | General Acute Care Hospital (282N00000X) |
United | 43198 | $190.89 | 1013949619 - MATTI PALO | 815294403 - (LA) JOINT EFFORTS LLC | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $195.03 | 1467556712 - LANCE ESTRADA | 814586583 - (LA) OANO, LLC | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $1276.00 | 1437419660 - ADVANCED SURGERY CENTER OF METAIRIE LLC | 453386956 - (LA) ADVANCED SURGERY CENTER OF METAIRIE | LA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43198 | $372.79 | 1841229978 - CAMBIZE SHAHRDAR | 203161166 - (LA) WK ORTHOPEDIC CLINIC | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $324.04 | 1295052041 - RAMIN SADEGHPOUR | 113542367 | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $335.70 | 1447707583 - MID STATE ORTHOPAEDIC & SPORTS MEDICINE CENTER LLC | 721310991 - (LA) MIDSTATE ORTHOPAEDIC & SPORTS MEDICINE CENTER, INC. | LA | Orthopaedic Surgery Physician (207X00000X) |
United | 43198 | $286.64 | 1508859612 - GONZALES HEALTHCARE SYSTEMS, MEMORIAL HOSPITAL | 741625013 | TX | General Acute Care Hospital (282N00000X) |
United | 43198 | $2664.00 | 1972640316 - BAYLOR ALL SAINTS MEDICAL CENTER | 751008430 - (TX) BAYLOR ALL SAINTS MEDICAL CENTER | TX | General Acute Care Hospital (282N00000X) |
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 43198 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43198 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 43198 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 |
|---|---|---|
| 43197-CPT | Moderate | Esophagoscopy, Flexible, Transnasal; Diagnostic, Including Collection Of Specimen(S) By Brushing Or Washing, When Performed (Separate Procedure) |
| 43198-CPT | Moderate | Once Per Dos Esophagoscopy, Flexible, Transnasal; W/Biopsy, Single Or Multiple |
| 43200-CPT | Moderate | Esophagoscopy Flexible Transoral; Diagnostic Including Collection Of Specimen(S) By Brushing Orwashing When Performed (Separate Procedure) (Revised 01/01/2014) |
| 43206-CPT | Moderate | Esophagoscopy Flexible Transoral; With Optical Endomicroscopy (Revised 01/01/2014) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43198. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43198 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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