CPT 81266 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 XU - Unusual Non-Overlapping Service |
| Complexity Level | Moderate |
| Medicare Fee Schedule | View Medicare rates for 81266 |
| Medicaid Fee Schedule | View Medicaid rates for 81266 |
National average reimbursement for CPT 81266 by major payers:
$228.41
$186.70
$269.58
$461.55
CPT 81266 vs. Other Molecular Pathology Procedures Codes
The CPT 81266 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 81266 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 |
|---|---|---|
| 81265-CPT | Low | Str Markers Specimen Anal, Comparative Analysis Using Short Tandem Repeat Str Markers Patient And Comparative Specimen Eg Pre Transplant Recipient And Donor Germline Testing Post Transplant Non Hematopoietic Recipient Germline Eg Buccal Swab Or Other Germline Tissue Sample And Donor Testing Twin Zygosity Testing Or Maternal Cell Contamination Of Fetal Cells |
| 81266-CPT | Moderate | Str Markers Spec Anal Addl, Comparative Analysis Using Short Tandem Repeat Str Markers Each Additional Specimen Eg Additional Cord Blood Donor Additional Fetal Samples From Different Cultures Or Additional Zygosity In Multiple Birth Pregnancies List Separately In Addition To Code For Primary Procedure |
| 81267-CPT | Low | Chimerism Anal No Cell Selec, Chimerism Engraftment Analysis Post Transplantation Specimen Eg Hematopoietic Stem Cell Includes Comparison To Previously Performed Baseline Analyses Without Cell Selection |
| 81268-CPT | Moderate | Chimerism Anal W Cell Select, Chimerism Engraftment Analysis Post Transplantation Specimen Eg Hematopoietic Stem Cell Includes Comparison To Previously Performed Baseline Analyses With Cell Selection Eg Cd3 Cd33 Each Cell Type |
What is a fee schedule?
A fee schedule is a list of fixed prices that healthcare providers charge for specific services, including CPT 81266. These prices vary depending on payer type (Medicare, Medicaid, private insurance), geographic location, and provider contracts.
Understanding the 81266 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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