CPT 81243 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 • 11 - Office |
| Common Modifiers | • None • 59 - Distinct Procedural Service • 90 - Reference Laboratory |
| Complexity Level | Low |
National average reimbursement for CPT 81243 by major payers:
$47.89
$34.98
$66.00
$115.69
| 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 81243 | ||||||
United | 81243 | $146.75 | 1235865502 - HSIAO TSAI | 951691313 - RADY CHILDRENS HOSPITAL-SAN DIEGO | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81243 | $34.22 | 1467442418 - NORTHWEST TEXAS HEALTHCARE SYSTEM INC, NORTHWEST TEXAS HEALTHCARE SYSTEM | 232238976 | TX | General Acute Care Hospital (282N00000X) |
United | 81243 | $23.95 | 1407191984 - BSA HOSPITAL LLC | 300754305 | TX | General Acute Care Hospital (282N00000X) |
United | 81243 | $225.27 | 1396014866 - KATHRYN SINGH | 330706882 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81243 | $76.12 | 1831403211 - HIND AL SAIF | 541581185 - MCV ASSOCIATED PHYSICIANS | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81243 | $51.34 | 1740910330 - BRENDEN PHUNG | 621647259 - TENNESSEE ONCOLOGY PLLC | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81243 | $193.02 | 1871568444 - JOANNE JETER | 274803222 - CITY OF HOPE MEDICAL FOUNDATION | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81243 | $313.01 | 1093975435 - ALLYSON SCOTT | 943281660 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81243 | $165.55 | 1871568444 - JOANNE JETER | 274803222 - CITY OF HOPE MEDICAL FOUNDATION | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81243 | $23.95 | 1902930381 - SANTA CLARA CO IPA | 473490581 - (CA) BAY AREA ACCOUNTABLE CARE NETWORK | CA | Ph.D. Medical Genetics (170100000X) |
United | 81243 | $193.02 | 1932343316 - KEVIN MCDONNELL | 274803222 - CITY OF HOPE MEDICAL FOUNDATION | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81243 | $57.04 | 1154618742 - VHS HARLINGEN HOSPITAL COMPANY LLC, VALLEY BAPTIST MEDICAL CENTER | 452662980 | TX | General Acute Care Hospital (282N00000X) |
United | 81243 | $23.95 | 1508199621 - SERGE LARTCHENKO M.D., PLLC | 270839735 - (TX) SERGE LARTCHENKO MD PLLC | TX | General Acute Care Hospital (282N00000X) |
United | 81243 | $23.95 | 1134126659 - CALDWELL MEMORIAL HOSPITAL INC | 720878037 - (LA) CALDWELL MEMORIAL HOSPITAL, INC. | LA | General Acute Care Hospital (282N00000X) |
United | 81243 | $85.55 | 1184622847 - CHI ST. LUKE'S HEALTH BAYLOR COLLEGE OF MEDICINE MEDICAL CENTER | 741161938 - CHI ST LUKES HEALTH BAYLOR COLLEGE OF MEDICINE 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 81243 vs. Other Molecular Pathology Procedures Codes
The CPT 81243 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 81243 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 |
|---|---|---|
| 81241-CPT | Low | F5 (Coagulation Factor V)(Eg Hereditary Hypercoagulability) Gene Analysis Leiden Variant |
| 81242-CPT | Low | Fancc (Fanconi Anemia, Complementation Group C) (Eg, Fanconi Anemia, Type C) Gene Analysis, Common Variant (Eg, Ivs4+4a>T) |
| 81243-CPT | Low | Fmr1(Fragile X Messenger Ribonucleoprotein 1) (Eg Fragile X Syndrome X-Linked Intellectual Disability [Xlid]) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles (Desc Rvsd 1/1/2024) |
| 81244-CPT | Low | Fmr1 (Fragile X Messenger Ribonucleoprotein 1) (Eg Fragile X Syndrome X-Linked Intellectual Disability [Xlid]) Gene Analysis; Characterization Of Alleles (Eg Expanded Size And Promoter Methylation Status) (Desc Rvsd 1/1/2024) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81243. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81243 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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