CPT 81164 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 | Pathology and Laboratory Procedures Molecular Pathology Procedures |
| Common Place of Service | 81 - Independent Laboratory |
| Common Modifiers | None 59 - Distinct Procedural Service 33 - Preventive Services |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 81164 |
| Medicaid Fee Schedule | View Medicaid rates for 81164 |
National average reimbursement for CPT 81164 by major payers:
$438.92
$358.11
$542.11
$856.22
CPT 81164 vs. Other Molecular Pathology Procedures Codes
The CPT 81164 code is part of the Pathology and Laboratory Procedures services used for Molecular Pathology Procedures. 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 81164 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 |
|---|---|---|
| 81162-CPT | High | Brca1 2 Gen Full Seq Dup Del, Brca1 Brca1 Dna Repair Associated Brca2 Brca2 Dna Repair Associated Eg Hereditary Breast And Ovarian Cancer Gene Analysis Full Sequence Analysis And Full Duplication Deletion Analysis Ie Detection Of Large Gene Rearrangements |
| 81163-CPT | Moderate | Brca1 2 Gene Full Seq Alys, Brca1 Brca1 Dna Repair Associated Brca2 Brca2 Dna Repair Associated Eg Hereditary Breast And Ovarian Cancer Gene Analysis Full Sequence Analysis |
| 81164-CPT | Moderate | Brca1 2 Gen Ful Dup Del Alys, Brca1 Brca1 Dna Repair Associated Brca2 Brca2 Dna Repair Associated Eg Hereditary Breast And Ovarian Cancer Gene Analysis Full Duplication Deletion Analysis Ie Detection Of Large Gene Rearrangements |
| 81165-CPT | Moderate | Genetic Test For Cancer, A Lab Analysis Of Genetic Material That Can Indicate Various Types Of Cancer. Types Of Analysis Include Gene Variants Full Sequence Analysis Or Breakpoints. |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81164. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81164 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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