CPT 52204 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 Urinary System |
| Common Place of Service | • 22 - On Campus-Outpatient Hospital • 24 - Ambulatory Surgical Center |
| Common Modifiers | • None • 59 - Distinct Procedural Service • XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service |
| Complexity Level | Moderate |
National average reimbursement for CPT 52204 by major payers:
$453.96
$539.53
$588.88
$643.00
| 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 52204 | ||||||
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CPT 52204 vs. Other Surgical Procedures on the Urinary System Codes
The CPT 52204 code is part of the Surgery services used for Surgical Procedures on the Urinary 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 52204 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 |
|---|---|---|
| 51940 | High | Close Exstrophy |
| 51960 | High | Enterocystoplasty W Bowel Anastomosis |
| 52007 | Moderate | Cystourethroscopy, With Ureteral Catheterization, With Or Without Irrigation, Instillation, Or Ureteropyelography, Exclusive Of Radiologic Service; With Brush Biopsy Of Ureter And/Or Renal Pelvis |
| 52204 | Moderate | C-Uscopy W Bx Office |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 52204. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 52204 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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