CPT 81260 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 • 50 - Federally Qualified Health Center |
| Common Modifiers | • None • 59 - Distinct Procedural Service • 90 - Reference Laboratory |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 81260 |
National average reimbursement for CPT 81260 by major payers:
$37.62
$24.09
$45.63
$89.77
| 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 81260 | ||||||
United | 81260 | $215.72 | 1730616541 - BARRY TONG | 943281660 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $194.13 | 1417935602 - JULIE MAK | 943281662 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $63.75 | 1326643511 - HAYLEY WRIGHT | 260089066 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $194.13 | 1083692354 - AMIE BLANCO | 943281662 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $25.43 | 1982371308 - ASHLEY REEVES | 822784244 - (MI) BEAUMONT MEDICAL GROUP - SPECIALTY SERVICES | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $194.13 | 1972034841 - DAVID BLAIR | 943281666 | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81260 | $133.02 | 1184736225 - STACY GRAY | 274803222 - CITY OF HOPE MEDICAL FOUNDATION | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81260 | $194.13 | 1851911705 - LAUREL HOCHSTETLER | 943281662 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $160.25 | 1518621390 - NIKHILA RAMESH | 956006143 - (CA) REGENTS UNIV OF CALIFORNIA | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $194.13 | 1184074460 - KANCHI BARFIWALA | 943281657 | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $194.13 | 1255548327 - JOSE CAMACHO | 943281657 | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81260 | $137.10 | 1821029414 - CHRISTINA BROCK | 237064656 - HEALING THE SOUL | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $16.51 | 1942683552 - CAITLIN HALE | 113650756 - (OR) MARC E. LEWIS, MD, LLC | CA | Genetic Counselor (M.S.) (170300000X) |
United | 81260 | $39.31 | 1972034841 - DAVID BLAIR | 943281660 | CA | Clinical Genetics (M.D.) Physician (207SG0201X) |
United | 81260 | $52.45 | 1730556259 - RAM SAHA | 541581185 - MCV ASSOCIATED PHYSICIANS | 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 81260 vs. Other Molecular Pathology Procedures Codes
The CPT 81260 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 81260 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 |
|---|---|---|
| 81255-CPT | Low | Hexa (Hexosaminidase A [Alpha Polypeptide]) (Eg, Tay-Sachs Disease) Gene Analysis, Common Variants (Eg, 1278instatc, 1421+1g>C, G269s) |
| 81257-CPT | Low | Hba/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syn- Drome Hbh Disease) Gene Analysis Common Deletions Or Variant (Eg Southeast Asian Thai Filipino Mediterranean Alpha3.7 Alpha4.2 Alpha20.5 And Constant Spring) (Desc Revised 1/1/2018) |
| 81258-CPT | Moderate | Hba1/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syndrome Hbh Disease) Gene Analysis; Known Familial Variant |
| 81260-CPT | Low | Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells, Kinase Complex-Associated Protein) (Eg, Familial Dysautonomia) Gene Analysis, Common Variants (Eg, 2507+6t>C, R696p) |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81260. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81260 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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