CPT 43496 Fee Schedule
Healthcare providers use this code to document and receive reimbursement for visits that address high-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 | • 21 - Inpatient Hospital • 24 - Ambulatory Surgical Center |
| Common Modifiers | • None • 62 - Co-Surgeons • 52 - Reduced Services • 82 - Assistant surgeon - no qualified resident • 51 - Multiple procedures • GC - Service performed by resident under supervision |
| Complexity Level | High |
| Medicare Fee Schedule | View Medicare rates for 43496 |
National average reimbursement for CPT 43496 by major payers:
$1,967.58
$2,776.68
$2,787.66
$4,041.10
| 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 43496 | ||||||
United | 43496 | $557.00 | 1295817435 - WILLS SURGERY CENTER OF CHERRY HILL, SURGERY CENTER OF CHERY HILL | 223335953 - (NJ) WILLS SURGERY CENTER OF CHERRY HILL | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $469.00 | 1386858595 - ALDERWOOD SURGERY CENTER LLC | 204979154 - (WA) ALDERWOOD SURGICAL CENTER | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $1064.00 | 1003004482 - SUMMIT AMBULATORY SURGICAL CENTER, LLC | 522148280 | MD | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $531.00 | 1528369972 - INSIGHT GROUP, LLC | 261871061 - (LA) INSIGHT GROUP LLC | LA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $1670.00 | 1629664156 - OSU WEXNER MEDICAL CENTER AMBULATORY SURGERY CENTER, OSU WEXNER MEDICAL CENTER AMBULATORY SURGERY CENTER NEW ALBANY | 854149946 - (OH) OSU WEXNER MEDICAL CENTER AMBULATORY SURGERY CENTER | OH | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $624.00 | 1619144607 - PACIFIC CATARACT AND LASER INSTITUTE, INC., P.C. | 911394965 - PACIFIC CATARACT AND LASER INSTITUTE, INC., PC | WA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $4300.00 | 1801974720 - SUMMIT SURGICAL CENTER, LLC | 731730859 | NJ | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $200.00 | 1477905271 - KATY ASC, LP, ADVANCED CARDIOVASCULAR & SURGERY CENTER AT METHODIST WEST HOUSTON | 813141435 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $825.00 | 1750386256 - PALOUSE SURGERY CENTER, LLC | 810593962 - (ID) PALOUSE SURGERY CENTER LLC | ID | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $356.00 | 1386618783 - LEWES DE ENDOSCOPY ASC LLC, SEASIDE ENDOSCOPY PAVILION | 562299727 - (DE) LEWES DE ENDOSCOPY ASC LLC | DE | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $112.00 | 1780604694 - CLEARVIEW SURGERY CENTER INC | 202828714 | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $1108.00 | 1851367486 - GRHS, LLC, ROCHESTER AMBULATORY SURGERY CENTER | 453685937 - (NY) ROCHESTER AMBULATORY SURGERY CENTER | NY | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $9043.00 | 1225064736 - NMC SURGERY CENTER, L.P., THE SURGERY CENTER OF NACOGDOCHES | 752793512 - (TX) NMC SURGERY CENTER LP | TX | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $852.00 | 1437250248 - GEORGIA SURGICAL CENTER ON PEACHTREE, LLC | 582394271 - (GA) GEORGIA SURGICAL CENTER ON PEACHTREE LLC | GA | Ambulatory Surgical Clinic/Center (261QA1903X) |
United | 43496 | $550.00 | 1407846215 - DAVIS EYE CENTER, INC, THE CENTER FOR SURGERY | 341554324 - (OH) DAVIS EYE CENTER, INC. | OH | 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 43496 vs. Other Surgical Procedures on the Digestive System Codes
The CPT 43496 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 43496 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.
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 43496. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 43496 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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