CPT 81261 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 | Genetic Analysis Procedures Tier 1 Molecular Pathology Procedures |
| Common Place of Service | 81 - Independent Laboratory 22 - On Campus Outpatient Hospital |
| Common Modifiers | None 59 - Distinct Procedural Service 26 - Professional component |
| Complexity Level | Low |
| Medicare Fee Schedule | View Medicare rates for 81261 |
National average reimbursement for CPT 81261 by major payers:
$165.99
$141.99
$199.67
$308.65
| Payer | Code | Rate | NPI | Tax ID | State | Specialty |
|---|---|---|---|---|---|---|
United | 81261 | $178.19 | 1225450588 - PARISH HOSPITAL SERVICE DISTRICT FOR THE PARISH OF ORLEANS, NEW ORLEANS EAST HOSPITAL | 273335876 | LA | General Acute Care Hospital (282N00000X) |
United | 81261 | $114.06 | 1023438009 - MOLLY MCINTOSH | 593140335 - BAYCARE MEDICAL GROUP INC | FL | Home Health Agency (251E00000X) |
United | 81261 | $271.32 | 1255478004 - CHRISTOPHER RAIO | 112050523 - ST FRANCIS HOSPITAL | NY | Emergency Medicine Physician (207P00000X) |
United | 81261 | $108.04 | 1366400376 - SUNRISE HOME HEALTH CARE INC. | 650307774 - (FL) SUNRISE HOME HEALTH CARE INC | FL | Home Health Agency (251E00000X) |
United | 81261 | $261.35 | 1255478004 - CHRISTOPHER RAIO | 111635088 - MERCY MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
United | 81261 | $197.99 | 1073502985 - CHU CHEN | 42484572 - MERRIMACK VALLEY PEDIATRIC ASSOCIATES, INC. | MA | Pediatrics Physician (208000000X) |
United | 81261 | $200.27 | 1821097627 - BAYCARE HOME CARE, INC. | 593582520 - (FL) BAYCARE HOME CARE INC | FL | Home Health Agency (251E00000X) |
United | 81261 | $148.55 | 1053725994 - HANS HENRIQUEZ | 363950044 - PROGRESSIVE MEDICAL CENTER, S.C. | IL | Internal Medicine Physician (207R00000X) |
United | 81261 | $135.06 | 1811000177 - CHARLESTON RADIOLOGISTS PA | 570634747 - CHARLESTON RADIOLOGISTS, P.A. | SC | Diagnostic Radiology Physician (2085R0202X) |
United | 81261 | $261.35 | 1255478004 - CHRISTOPHER RAIO | 113438973 - ST JOSEPH HOSPITAL | NY | Emergency Medicine Physician (207P00000X) |
United | 81261 | $83.16 | 1366428401 - AARON ASKEW | 931261079 - THE ORTHOPEDIC AND NEUROSURGICAL CENTER OF THE CASCADES | OR | Orthopaedic Trauma Physician (207XX0801X) |
United | 81261 | $106.91 | 1255478004 - CHRISTOPHER RAIO | 111635088 - MERCY MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
United | 81261 | $128.69 | 1871162834 - AHS HOSPITAL CORP, AHS CONSOLIDATED LABS | 521958352 - ATLANTIC HEALTH SYSTEM INC | NJ | Clinical Medical Laboratory (291U00000X) |
United | 81261 | $294.10 | 1023335643 - VINEETHA ALIAS | 521958352 - ATLANTIC HEALTH SYSTEM INC | PA | Pediatrics Physician (208000000X) |
United | 81261 | $271.32 | 1255478004 - CHRISTOPHER RAIO | 111888924 - GOOD SAMARITAN HOSPTIAL MEDICAL CENTER | NY | Emergency Medicine Physician (207P00000X) |
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 81261 vs. Other Tier 1 Molecular Pathology Procedures Codes
The CPT 81261 code is part of the Genetic Analysis Procedures services used for Tier 1 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 81261 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 |
|---|---|---|
| 81251-CPT | Low | Gaucher Disease Genetic Test, A Lab Analysis Of Genetic Material That Can Indicate Gaucher Disease. Types Of Analysis Include Gene Variants Full Sequence Analysis Or Breakpoints. |
| 81252-CPT | Low | Genetic Test For Hearing Loss, A Lab Analysis Of Genetic Material That Can Indicate The Likelihood Of Developing Hearing Loss. Types Of Analysis Include Gene Variants Full Sequence Analysis Or Breakpoints. |
| 81260-CPT | Low | Ikbkap (Inhibitor Of Kappa Lig, Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells Kinase Complex-Associated Protein) (Eg Familial Dysautonomia) Gene Analysis Common Variants (Eg 25076tc R696p) |
| 81261-CPT | Low | Igh Gene Rearrange Amp Meth, Igh Immunoglobulin Heavy Chain Locus Eg Leukemias And Lymphomas B Cell Gene Rearrangement Analysis To Detect Abnormal Clonal Population S Amplified Methodology Eg Polymerase Chain Reaction |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81261. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81261 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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