CPT code 49505 reports an open repair of an initial, reducible inguinal hernia in a patient age 5 or older. Adults fall under it too; the age floor only separates it from the pediatric codes. For 2026, Medicare pays a national $508.03 for it, and it carries a 90-day global period.
Most denials on this code come from picking the wrong neighbor: a recurrent hernia billed as initial, or a trapped hernia sent out as reducible. Get the code selection right, keep mesh off the claim, and match each payer’s modifier format, and 49505 pays on the first submission.
The AMA descriptor reads: “Repair initial inguinal hernia, age 5 years or older; reducible.” In plain terms, it’s an open inguinal hernia repair: the surgeon opens the groin, pushes the hernia contents back into the abdomen, and closes the weak spot in the inguinal canal. Op notes often call it an inguinal herniorrhaphy or hernioplasty.
Some lay summaries describe the patient as “a child, five years of age or older,” and that wording confuses coders. A 30-year-old qualifies. So does an 80-year-old. The age 5 threshold exists to route younger patients to their own codes, and it sets no upper limit.
Miss any one of the four, and a different code applies. A laparoscopic or robotic repair moves to its own codes, and a documented prior repair on the same side moves the claim to the recurrent codes.
The inguinal hernia repair CPT code family runs from 49491 to 49525 for open repairs, plus 49650 and 49651 for laparoscopic work. Three facts on the op note decide the code: the approach, any prior repair on that side, and whether the hernia reduced. Age matters only for initial open repairs.
| Scenario on the op note | CPT code |
|---|---|
| Open, initial, age 5 or older, reducible | 49505 |
| Open, initial, age 5 or older, incarcerated or strangulated | 49507 |
| Open, initial, age 6 months to younger than 5 (reducible / incarcerated) | 49500 / 49501 |
| Open, initial, full-term infant under 6 months or preterm infant over 50 weeks postconception (reducible / incarcerated) | 49495 / 49496 |
| Open, initial, preterm infant up to 50 weeks postconception (reducible / incarcerated) | 49491 / 49492 |
| Open, recurrent, any age (reducible / incarcerated or strangulated) | 49520 / 49521 |
| Open, sliding hernia, any age | 49525 |
| Laparoscopic or robotic (initial / recurrent) | 49650 / 49651 |
Approach is the only difference between these two. 49505 describes an open repair through a groin incision. 49650 describes a laparoscopic repair through ports with a camera, and a robotic repair reports 49650 as well. Age and reducibility have no bearing on 49650, which our CPT 49650 billing guide covers in full.
Conversions cause the most confusion. If the surgeon starts with a laparoscopic approach and converts to open, report the open code, which is 49505 for an initial reducible hernia. Make sure the op note states the reason for the conversion, such as dense adhesions, unclear anatomy, or bleeding.
CPT code 49507 covers the same open, initial repair in a patient age 5 or older, with one change: the hernia was incarcerated or strangulated. Incarcerated means the contents stayed trapped and wouldn’t reduce. Strangulated means the trapped tissue lost its blood supply. If the surgeon reduced the hernia, 49507 doesn’t fit.
49520 covers a recurrent reducible hernia at any age, so a documented prior repair on the same side sends the claim there. A sliding hernia, where an organ such as the bladder or colon forms part of the sac, goes to 49525 regardless of age or status.
Yes. Mesh placement is part of 49505, and the surgeon can’t bill it on a separate line. The 2026 NCCI Policy Manual, Chapter 6 bars mesh or prosthesis implantation codes from being reported with a hernia repair unless CPT instructions allow it. No CPT instruction allows it for an inguinal repair.
Some chargemasters still carry +49568, the old mesh add-on. CPT deleted it on January 1, 2023, and it only ever applied to incisional and ventral repairs. If your system still splits an inguinal hernia repair with mesh into two lines, fix that mapping before the next claim goes out.
The facility claim follows its own rules. A hospital outpatient department can list the mesh under HCPCS C1781, and Medicare packages that payment into the procedure. That line belongs on the hospital’s claim, while the surgeon’s claim carries 49505 alone.
A one-sided repair doesn’t need a modifier under CPT rules, but most payers still want RT or LT. A left inguinal hernia repair goes out as 49505-LT, and a right inguinal hernia repair goes out as 49505-RT. Leaving laterality off is a common route to a CO-4 denial.
Medicare wants a single line: 49505 with modifier 50 and one unit. Under the CMS Claims Processing Manual, Chapter 12, Medicare pays bilateral procedures at 150% of the one-side amount. At the 2026 national rate, that works out to about $762.05 before geographic adjustment.
Commercial payers split on format. Some accept 49505-50 on one line, and others want two lines with RT and LT. Check each payer’s bilateral policy before you submit, and check the current quarter’s CMS MUE table when a payer questions your units.
If bilateral and laterality edits keep bouncing your hernia claims, a second set of eyes can save weeks of rework. See how our medical billing services handle surgical claims across surgical specialties, including general surgery and ASC cases.
Surgeons often fix more than the hernia. Whether an added procedure gets its own line depends on the patient’s age, the incision, and whether the work was separate from the hernia sac.
The lipoma rule starts the most arguments. Coding Clinic for HCPCS allows 55520 when the op note describes the lipoma excision as separate from the hernia sac dissection. Our breakdown of modifier 59 and X modifiers explains which one fits your scenario.
Medicare’s 2026 national payment for CPT code 49505 is $508.03. That figure comes from 15.21 total RVUs multiplied by the $33.4009 conversion factor for practitioners outside qualifying APMs. It’s the facility amount, since surgeons perform this repair in a hospital or ASC, and your MAC locality adjusts it through the GPCIs.
| 2026 Medicare value | CPT 49505 |
|---|---|
| Work RVU | 7.76 |
| Practice expense RVU (facility) | 5.40 |
| Malpractice RVU | 2.05 |
| Total RVU | 15.21 |
| Conversion factor (non-qualifying APM) | $33.4009 |
| National payment | $508.03 |
| Global period | 090 |
Pull your local amount from the CMS PFS Look-Up Tool instead of copying a national figure into your fee schedule. CMS posted the October 2026 RVU release, RVU26D, on August 26, 2026, so use the current quarter when you update charges.
The non-APM conversion factor rose 3.26% for 2026, yet 49505 fell from $515.60 to $508.03, a 1.47% drop. The CY 2026 PFS final rule (CMS-1832-F) cut work RVUs 2.5% for non-time-based services and trimmed indirect practice expense for facility-based work.
The facility bills its own claim. For 2026, Medicare’s national facility rate runs about $3,658 in a hospital outpatient department under APC 5341 and about $1,744 in an ASC. The surgeon’s claim uses POS 22 for on-campus hospital outpatient cases, and our POS 22 billing guide covers that setup.
Patients see a different number. Medicare.gov’s Procedure Price Lookup shows an average patient cost of $449 for 49505 in an ASC and $832 in a hospital outpatient department, with facility and doctor fees combined.
CPT 49505 carries a 090 global period: the day before surgery, the day of surgery, and 90 days after. Related follow-up visits inside that window carry no charge of their own. Many practices log them with 99024 so the visit still shows in the record.
Watch the decision visit. Coders often put 25 on it, and Medicare expects 57 for a 90-day global procedure, as the CMS Global Surgery Booklet lays out.
If the surgeon explores the groin and finds no hernia, don’t send 49505 as though a repair happened. Route that op note to a coder first, since payers vary on how they handle a negative exploration and the claim has to match what the surgeon did.
Payers compare the diagnosis against the CPT descriptor, so a recurrent or obstructed diagnosis on a 49505 line invites a CO-11 denial. The K40 codes below are current in the FY 2027 ICD-10-CM code set, which took effect October 1, 2026.
| ICD-10-CM | What it means | Matching CPT |
|---|---|---|
| K40.90 | Unilateral, no obstruction or gangrene, not recurrent | 49505 with RT or LT |
| K40.20 | Bilateral, no obstruction or gangrene, not recurrent | 49505-50 |
| K40.91 / K40.21 | Unilateral / bilateral, no obstruction or gangrene, recurrent | 49520 |
| K40.30 / K40.00 | Unilateral / bilateral, with obstruction, not recurrent | 49507 |
| K40.40 / K40.10 | Unilateral / bilateral, with gangrene, not recurrent | 49507 |
| Denial | What went wrong | Fix |
|---|---|---|
| CO-11 | Recurrent or obstructed diagnosis on a 49505 line | Recode to 49520 or 49507, or correct the diagnosis |
| CO-97 | Mesh, femoral repair, or lipoma billed without separate work | Remove the bundled line, or document the separate site and add 59 or XS |
| CO-4 | Missing RT or LT, or the wrong bilateral format for that payer | Match the payer’s laterality and bilateral format |
| CO-50 | Payer questions medical necessity for an asymptomatic hernia | Document symptoms, exam findings, and the reason for repair |
| CO-197 | No prior authorization on a plan that requires it | Verify authorization when the case gets scheduled |
Most of these start in the op note or the chargemaster. Fix the source once, and the same denial stops repeating across the surgeons in your group. A clean claim on 49505 comes down to those two inputs.
If hernia denials pile up faster than your team can appeal them, our denial management services work each one back to its root cause and fix the workflow behind it.
No. CPT 49505 covers any patient age 5 or older, adults and seniors included. Patients younger than 5 get the pediatric codes 49491 to 49501, which also include hydrocelectomy. The age wording in the descriptor sets a floor and has no upper limit.
Yes. The 2023 hernia overhaul deleted the old umbilical, ventral, and incisional repair codes and replaced them with 49591 to 49618. The inguinal codes, 49491 to 49525, stayed out of that change, and 49505 remains active for 2026.
It depends on the plan. Original Medicare doesn’t require prior authorization for inguinal hernia repair, but many Medicare Advantage and commercial plans do for elective cases. Verify it during scheduling, because a missing authorization leads to a CO-197 denial.
Clean 49505 claims come down to three things: the right code for approach, history, and reducibility; mesh kept off the claim; and the modifier format each payer expects. Get those right, and the 49505 CPT code turns into one of the more predictable surgical claims you send.
If your surgical claims need a closer look, ClaimMax RCM can start with a free Revenue Cycle Health Score. It shows where your general surgery claims lose money and what to fix first.
From there, our team can take over coding, submission, and follow-up through full revenue cycle management, so your staff spends less time on rework and more time on patients.
The 99347 CPT code reports an evaluation and management (E/M) visit for an established patient in their home or residence. It’s the lowest level in the established home visit series. A visit qualifies with straightforward medical decision making (MDM) or at least 20 minutes of total practitioner time on the date of service.
Medicare’s 2026 national rate for 99347 is $46.09. Since January 1, 2026, Medicare also pays the G2211 add-on with it. Several pages that rank for this code still list the old 15-minute time, so check the date on any source before you rebuild a template around it.
| Item | 2026 detail |
|---|---|
| Code family | Home or residence services, established patient (99347 to 99350) |
| Level selection | Straightforward MDM, or at least 20 minutes of total time on the date of service |
| Patient type | Established: seen by you or a same-specialty practitioner in your group within three years |
| Settings and POS | Home (12), assisted living (13), group home (14), custodial care facility (33), residential substance abuse facility (55) |
| 2026 Medicare national rate | $46.09 (standard conversion factor); $46.32 for Qualifying APM Participants |
| RVUs | 0.90 work, 0.44 practice expense, 0.04 malpractice, 1.38 total |
| G2211 add-on | Payable with 99347 for dates of service on or after January 1, 2026 |
| Telehealth | On the CY 2026 Medicare Telehealth Services List |
| CMS status and global | Active (status A), global period XXX |
CPT code 99347 covers an in-person E/M visit for an established patient where that patient lives. The official 99347 CPT code description calls for a medically appropriate history or exam plus straightforward MDM. If you pick the level by time instead, the visit needs 20 minutes or more of total time on the encounter date.
Picture the home version of a quick office follow-up. A practitioner travels to the patient, handles one minor issue or confirms a stable plan, and documents it. House call practices, home-based primary care groups, and clinicians who round in assisted living facilities bill this code week after week.
The AMA rebuilt this family on January 1, 2023. According to the AMA’s E/M code changes, it deleted the domiciliary and rest home codes 99334 to 99340, merged that work into 99341 to 99350, and dropped new patient code 99343. History and exam no longer set the level. MDM or total time does, the same way office visits work.
Before 2023, 99347 listed a problem-focused history and exam with about 15 minutes of typical face-to-face time. If a superbill, EHR template, or payer edit still shows that wording, update it. A 17-minute visit documented under the old logic won’t support 99347 by time today.
You can support the 99347 CPT code one of two ways: straightforward MDM or 20 minutes of total time. Pick the pathway your note supports better. You don’t need both, though documenting both gives you a fallback if an auditor questions one of them.
MDM has three elements: problems addressed, data reviewed, and risk of the management plan. The AMA 2023 E/M guidelines require two of the three to meet or exceed a level. Compare straightforward with low, the level that moves a visit to 99348:
| MDM element | Straightforward (99347) | Low (99348) |
|---|---|---|
| Problems | One self-limited or minor problem | One stable chronic illness, one acute uncomplicated illness or injury, or two or more minor problems |
| Data | Minimal or none | Two items, such as reviewing an external note and a test result, or using an independent historian |
| Risk | Minimal risk from further testing or treatment | Low risk from further testing or treatment |
Total time counts the work the billing practitioner does on the date of service, face to face or not. CMS lists these activities in its E/M booklet:
Travel doesn’t count. The AMA guidelines rule out travel time for home visit levels, and CMS also excludes time spent on services you report on their own claim line. Clinical staff time stays out as well. Write the exact minutes, for example “22 minutes total, including chart review and documentation.” Auditors push back on “over 20 minutes.”
Scenario one. A caregiver calls about a mild rash on an 84-year-old patient’s forearm. The nurse practitioner visits, examines it, and recommends an over-the-counter cream. That’s one minor problem with no data reviewed. Two of three elements sit at straightforward, so 99347 fits.
Scenario two. A physician checks a patient with stable hypertension (I10) and changes nothing. The problem element reaches low, but data and risk stay at straightforward. With only one element at low, the visit still lands on 99347.
Scenario three. Same patient, but the physician adjusts the lisinopril dose. The AMA classifies prescription drug management as moderate risk. Problems now meet low and risk exceeds it, so the visit supports 99348. At 2026 national Medicare rates, missing that step costs $32.74 per visit ($78.83 minus $46.09).
The CPT code for a home visit with an established patient depends on the level, and 99347 sits at the bottom of four. The levels differ by MDM, minimum time, and what Medicare pays for each one.
| Code | MDM level | Minimum total time | 2026 national Medicare rate |
|---|---|---|---|
| 99347 | Straightforward | 20 minutes | $46.09 |
| 99348 | Low | 30 minutes | $78.83 |
| 99349 | Moderate | 40 minutes | $132.27 |
| 99350 | High | 60 minutes | $193.06 |
Each time is a minimum, not a range. A 29-minute visit stays at 99347 by time unless MDM supports 99348. New patients use 99341, 99342, 99344, or 99345, and the moderate level is covered in our CPT 99349 billing guide.
Prolonged service codes don’t attach to 99347. Medicare’s G0318 starts at 110 minutes, and only on 99350. Other payers may accept CPT 99417 for prolonged services, which Medicare doesn’t pay, but it also applies only above the top level.
CMS lists five residence settings for this code family in MLN006764 (CMS E/M booklet). The place of service (POS) code on the claim has to match where the patient lives.
| POS | Setting | Typical example |
|---|---|---|
| 12 | Home | Private residence, or temporary lodging such as a hotel or campground |
| 13 | Assisted living facility | Resident in an assisted living apartment |
| 14 | Group home | Group home not licensed as an intermediate care facility for individuals with intellectual disabilities |
| 33 | Custodial care facility | Residential setting providing room, board, and personal care |
| 55 | Residential substance abuse treatment facility | Live-in treatment setting |
Nursing facility and skilled nursing patients don’t qualify. The AAFP home visit coding update points those visits to 99304 to 99310. If you’re unsure how a facility is licensed, check its definition in the CMS Place of Service code set.
Noridian’s home visit guidance says the physician must be physically present in the beneficiary’s home to bill these codes. Medicare’s recovery auditors run an automated review, RAC topic 0011, that flags home visit codes billed during a hospital inpatient stay. Confirm admission dates before you submit for patients with recent hospital trips.
Medicare won’t pay the 99347 CPT code for a house call that happened for convenience. Noridian’s guidance sets these rules for every home visit note:
Homebound status isn’t required for 99347. That test belongs to the Medicare home health benefit, which agencies bill with a separate set of home health CPT codes. Your note still needs a medical reason the patient was seen at home instead of in the office.
List the condition you treated first. Then add status codes that explain why the patient couldn’t come in, when they apply:
Back each code with one sentence in the note. “Patient uses a wheelchair and needs a two-person assist to get into a car” gives a reviewer the reason in seconds.
Physicians, nurse practitioners, and physician assistants can bill 99347 under their own NPI when state scope of practice allows E/M services. The patient has to be established, meaning you or another practitioner of the same specialty in your group saw them within the past three years.
Enroll each NP or PA with every payer before their first solo home visit through provider credentialing and enrollment, or those claims will deny.
If home visit levels keep sending claims back for rework, our medical billing services team codes and submits E/M claims like these every day. We can look at your recent home visit denials and tell you where they started.
Medicare’s 2026 national payment for 99347 is $46.09 for most clinicians. The CMS RVU26D relative value file (October 2026 release) lists 0.90 work RVUs, 0.44 practice expense RVUs, and 0.04 malpractice RVUs, for 1.38 total. Multiply 1.38 by the 2026 conversion factor of $33.4009 and you get $46.09.
Clinicians who are Qualifying APM Participants (QPs) get a separate $33.5675 conversion factor, which works out to $46.32.
The file shows the same 1.38 total in the facility and nonfacility columns, so assisted living and private home visits pay the same base amount. Medicare pays 80% of the allowed amount after the Part B deductible, and the patient owes the 20% coinsurance.
Medicare adjusts each RVU by your locality’s geographic practice cost index (GPCI). We applied the 2026 GPCI file to 99347’s RVUs:
| Medicare locality | 2026 99347 amount |
|---|---|
| Alaska (statutory 1.5 work GPCI floor) | $61.48 |
| Manhattan, NY | $51.18 |
| Los Angeles, CA | $49.57 |
| Chicago, IL | $48.11 |
| Rest of Texas | $45.21 |
| Alabama | $43.68 |
| Arkansas (lowest) | $43.37 |
We calculated these from CMS files, so they can differ by a few cents from the CMS Physician Fee Schedule search tool because of rounding. Use the lookup tool for the exact amount in your area.
For dates of service on or after January 1, 2026, the CMS CY 2026 final rule summary (MM14315) adds G2211 to the home or residence family, 99347 included. The add-on carries 0.52 nonfacility RVUs, or $17.37 at the national rate. On a 99347 visit, that raises the national payment from $46.09 to $63.46, about 38% more.
G2211 fits when you serve as the patient’s continuing focal point for care, or you manage a single serious or complex condition over time. A one-time visit for a patient you won’t follow doesn’t qualify.
CMS doesn’t pay G2211 when the base E/M carries modifier 25, unless the other same-day service is an annual wellness visit, vaccine administration, or a Part B preventive service. Your MAC can tell you whether that exception carries over to home visits, since CMS wrote it for office visits. Pairing rules for annual wellness visit billing follow the same logic.
Some claim scrubbers still drop G2211 from home visit lines because the add-on used to pair only with office visits. Pull a recent batch of remits and look for it. If it’s missing, our revenue cycle management team can trace where it falls off.
Yes, under Medicare’s telehealth rules. 99347 appears on the CY 2026 Medicare Telehealth Services List. The CMS telehealth FAQ (February 2026) confirms that through December 31, 2027, beneficiaries can receive telehealth anywhere in the United States, including at home. Report POS 10 when the patient is at home.
A video claim is a telehealth service, and POS 12 billing still requires you in the room. Commercial payers set their own telehealth policies, so check each contract before you bill 99347 by video. Some also want a telehealth modifier, which our modifier 95 guide explains.
Run insurance eligibility verification before the visit. Then confirm the note shows:
Home visit, POS 12. Established patient, last seen June 2026.
CC: Caregiver reports a red, itchy patch on the left forearm for two days.
Reason for home visit: Patient uses a wheelchair (Z99.3) and needs a two-person assist for transport.
Exam: 3 cm erythematous patch, no drainage, no warmth, no spread.
Assessment: Contact dermatitis (L30.9), likely from a new laundry soap.
Plan: Stop the soap. OTC hydrocortisone 1% twice daily for seven days. Caregiver to call if it spreads.
MDM: Straightforward. One minor problem, no data reviewed, low risk.
Total time on date of service: 21 minutes.
Each denial below ties to a specific, fixable error. The claim adjustment reason codes (CARCs) come from the X12 CARC code list.
| Denial | Likely cause | Fix |
|---|---|---|
| CARC 5 or 58 (place of service) | POS 11 or POS 12 billed for an assisted living resident | Match POS to the residence (13 for assisted living) and send a corrected claim |
| CARC 50 (medical necessity) | Note doesn’t say why the visit happened at home | Add the reason the patient couldn’t travel, then appeal with records |
| CARC 16 (missing information) | Missing time statement, rendering NPI, or other claim data | Complete the field and resubmit |
| New patient billed as established | No same-specialty visit in the past three years | Rebill with 99341, 99342, 99344, or 99345 |
| Inpatient overlap (RAC 0011) | Home visit dated during a hospital admission | Verify admission dates and void the line if the patient was inpatient |
| G2211 missing or denied | Scrubber strips it, or modifier 25 sits on the base code | Add G2211 when criteria are met and review modifier 25 use |
Read the remittance advice remark code (RARC) next to each CARC. It tells you whether the payer wants a corrected claim or a reconsideration. If home visit denials pile up close to their appeal deadlines, our denial management services team sorts them by root cause so the same error stops repeating.
Bill 99347 for an established patient you see in person at their residence. Support it with straightforward MDM or 20 or more minutes of total time, use the POS code that matches the residence, and document why the visit happened at home. Add G2211 when you’re the patient’s ongoing focal point for care.
CPT code 99347 is the lowest level of established patient home or residence E/M visit. It requires a medically appropriate history or exam and straightforward MDM, or 20 minutes of total time on the date of service. It belongs to the 99347 to 99350 series.
Medicare lists 99347 as a telehealth service for 2026, and patients can receive telehealth at home through December 31, 2027. Bill it with POS 10 as a telehealth claim. An in-person home visit billed with POS 12 requires the practitioner to be physically present. Commercial payers set their own telehealth rules.
Established patient home or residence visits use 99347 to 99350. 99347 is straightforward MDM or 20 minutes, 99348 is low MDM or 30 minutes, 99349 is moderate MDM or 40 minutes, and 99350 is high MDM or 60 minutes. New patients use 99341, 99342, 99344, and 99345.
The 2026 national Medicare rate for 99347 is $46.09, based on 1.38 total RVUs and a $33.4009 conversion factor. Qualifying APM participants receive $46.32. Your amount depends on your locality, ranging from about $43.37 in Arkansas to $51.18 in Manhattan, with Alaska higher because of its GPCI floor.
No. CMS lists 99347 as active (status A) in its October 2026 relative value file. The last structural change came in 2023, when the AMA set the 20-minute threshold and moved level selection to MDM or time. Medicare’s main 2026 change is paying G2211 with it.
No. Homebound status applies to the Medicare home health benefit, not to physician home visits. The note still has to show a medical reason for seeing the patient at home instead of the office, and the problem has to be active.
At $46.09, a 99347 claim leaves little room for rework. Get the POS code, established status, medical necessity statement, and G2211 right on the first pass, and you keep that margin. Pull your last 30 home visit claims and tally which of those four caused each denial.
ClaimMax RCM handles home visit billing for practices that run house calls and assisted living rounds. If you’d like another set of eyes on those claims, talk to our billing team.
The 99281 CPT code is the level 1 emergency department (ED) visit. It’s the lowest of five ED levels. The American Medical Association (AMA) describes it as an “Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional.”
In practice, 99281 covers minimal services in a hospital ED, such as uncomplicated suture removal, where clinical staff do the hands-on work under supervision. The American College of Emergency Physicians (ACEP) says few ED patients fit this level. That makes it a rare code on physician claims, and urgent care operators sometimes reach for it by mistake.
Billers at ED groups and hospitals get two rules wrong more than any others. Only a physician or qualified health care professional (QHP) reports 99281, even when a nurse does the work. Triage alone doesn’t support the code. Payers edit for both, and if your charge rules get either one wrong, you’ll repeat the error on every low-acuity ED claim.
Before a 99281 claim leaves your system, check it against each row below. The source behind every rule sits in parentheses beside it.
| What to check | 99281 rule (source) |
|---|---|
| Code level | Level 1 of five ED E/M levels (AMA) |
| Medical decision making (MDM) | Doesn’t apply (AMA, AAFP) |
| Time | Not used to pick any ED level (AMA) |
| Who does the face-to-face work | Clinical staff may, under supervision (AMA) |
| Who reports the code | A physician or QHP only (AMA) |
| Supervision | Direct supervision; the physician doesn’t need to be at the bedside (Medicare contractor guidance) |
| Patient status | New or established; ED codes make no distinction (AMA) |
| Setting | A hospital-based ED available 24 hours a day (AMA); place of service 23 on the professional claim |
| Typical visits | Uncomplicated suture removal, dressing changes, packing removal (ACEP) |
| 2026 Medicare national payment, professional | $11.02 (CMS) |
| 2026 Medicare national payment, facility | $86.15, APC 5021, Type A ED (CMS OPPS, via ACEP) |
| Global period | XXX, the standard for E/M codes (CMS) |
| Modifiers | None routinely; modifier 25 only for a significant, separately identifiable E/M with a same-day procedure (CPT) |
CPT code 99281 means a level 1 ED visit for a problem that may not need a physician or QHP in the room. It’s the only ED level without a medical decision making (MDM) level. Time plays no part in choosing it.
The 99281 CPT code description turns on one phrase: a patient “that may not require the presence of a physician or other qualified health care professional.” In the AMA’s 2023 E/M guidelines, that patient’s issue counts as a minimal problem. A clinician doesn’t have to be present, yet the service still runs under a physician’s or QHP’s supervision.
CPT defines a QHP as someone qualified by education, training, licensure, and facility privileging who works within their scope of practice and “independently reports that professional service.” Nurse practitioners and physician assistants meet that definition in most cases. An ED nurse counts as clinical staff, and clinical staff don’t report services on their own.
MDM measures three things: the problems addressed, the data reviewed, and the risk of patient management. For 99281, the AMA sets that grid aside: “The concept of the level of MDM does not apply to 99211, 99281.” The AAFP’s E/M level table says the same. Straightforward MDM belongs to 99282, one level up.
Any payer table or AI answer that pins straightforward MDM on 99281 is describing the wrong code. Time doesn’t help either. The AMA says time “is not a descriptive component for the emergency department levels,” because ED physicians work at variable intensity across several patients at once. That’s the whole CPT code 99281 definition: a descriptor plus a supervision requirement.
Before 2023, 99281 required three key components: a problem-focused history, a problem-focused exam, and straightforward MDM. On January 1, 2023, CPT replaced them with today’s descriptor, and all five ED codes stopped using history and exam to set the level. A template that still asks for a “problem-focused” exam follows a retired standard.
Some payer policies we reviewed in 2026 still label 99281 “straightforward.” Follow each payer’s written policy on that payer’s claims, and code to CPT everywhere else.
An ED level is one of five CPT codes, 99281 to 99285, that describe how much evaluation and management an emergency department visit needed. Level 1 has no MDM level. Levels 2 to 5 climb from straightforward to high MDM, and a group reports one ED level per patient encounter.
| Level | CPT code | MDM required | Typical problem (CPT terms) | 2026 Medicare national, professional |
|---|---|---|---|---|
| 1 | 99281 | Doesn’t apply | Minimal problem; may not need a physician or QHP present | $11.02 |
| 2 | 99282 | Straightforward | One self-limited or minor problem | $40.42 |
| 3 | 99283 | Low | For example, one acute, uncomplicated illness or injury | $69.47 |
| 4 | 99284 | Moderate | For example, an acute illness with systemic symptoms, or an undiagnosed new problem with uncertain prognosis | $118.24 |
| 5 | 99285 | High | For example, an illness or injury that poses a threat to life or bodily function | $171.35 |
Payments equal total RVUs (0.33, 1.21, 2.08, 3.54, and 5.13) times the $33.4009 CY 2026 conversion factor, before geographic adjustment.
Across emergency room levels 1 to 5, the leveling rule changes at level 2. From 99282 up, the chart needs two of the three MDM elements at or above the level’s threshold. A patient who asks what “level 4” means on an ER bill is looking at a 99284 visit with moderate MDM.
The CPT code for an emergency room visit is one of these five, chosen by the MDM the chart supports. Our CPT 99283 guide covers the low-MDM level in depth. High-MDM visits, and the denials they draw, get their own walkthrough in the 99285 billing guide.
Two neighbors sit outside the five levels. CPT 99288 covers a physician’s direction of emergency medical services crews by two-way radio or phone. Critical care, 99291 and 99292, runs on time instead of MDM and starts at 30 minutes of critical care.
The 99281 CPT code fits a narrow set of visits: a registered ED patient who needs a minimal service that clinical staff can perform under supervision. ACEP’s coding committee calls it “improbable that many patients that present to the emergency department clinically fit into this category.” Most who fit are back for wound care.
ACEP’s ED coding FAQ expects level 1 patients to come back for one of these:
ACEP rates the risk of removing sutures or packing from a well-healed wound as minimal, since complications are rare. Picture a patient back on day 10. Another facility placed her sutures, and your nurse removes them after checking the wound. She reviews home care, and her note names the supervising physician. That visit supports 99281.
According to ACEP, two common add-ons take a visit past level 1. A tetanus shot is one. ACEP treats the decision to give it as a moderate-risk treatment choice, the same tier as prescription drug management. Injectable lidocaine is the other, since it needs a prescription.
Repacking a wound or starting an antibiotic moves past minimal risk too. So does any test the physician orders, because level 1 has no room for data review. If a physician or QHP personally evaluates a self-limited or minor problem and documents straightforward MDM, the visit is 99282.
Some example lists put medication refills at level 1. Managing a prescription is a moderate-risk decision under the MDM table, so a refill visit doesn’t belong there.
Diagnosis coding for a level 1 visit stays in the Z48 aftercare family in most cases. All three codes below are valid for HIPAA transactions in the FY2027 code set, effective October 1, 2026.
| ICD-10-CM | Description | Typical 99281 visit |
|---|---|---|
| Z48.02 | Encounter for removal of sutures | Suture removal |
| Z48.00 | Encounter for change or removal of nonsurgical wound dressing | Dressing change after an injury |
| Z48.01 | Encounter for change or removal of surgical wound dressing | Dressing change after surgery |
If the nurse finds infection or a reopened wound, code the complication instead. A physician now has to evaluate it, so the level rises in most cases.
An ED nurse or other clinical staff member can perform the hands-on part of a 99281 visit, but only a physician or QHP reports the code. The AMA values 99281 as the supervising physician’s work, because the hospital employs the nurse and covers her time in its own facility charge.
The AMA’s guideline is direct: “For 99211 and 99281, the face-to-face services may be performed by clinical staff.” CPT’s clinical staff member works under supervision, can perform or assist with a service, and “does not individually report that professional service.” Think of the nurse removing sutures under a standing protocol while the attending sees other patients.
AMA’s CPT webinar FAQ settles the billing question: “Only physicians or other QHPs are able to report the service.” According to the same answer, the work RVUs pay for supervision, and 99281 has no direct practice expense inputs because the staff belong to the facility.
On the professional side, the 99281 CPT code goes out on the CMS-1500 under the supervising physician’s or QHP’s NPI. Medicare’s incident-to rules don’t apply to hospital services, so the nurse’s time can’t move onto the physician’s claim. Some guides and AI answers say nurses bill 99281 on their own. The AMA says only a physician or QHP reports it.
Wellpoint Federal, the Medicare Administrative Contractor formerly called National Government Services, says 99281 “requires direct supervision of a physician or NPP but does not require personal supervision at the bedside.” The supervising clinician can stay with other patients. Name that person in the note, though, because the claim goes out under that NPI.
Specialists use the same code family. Under the Medicare Claims Processing Manual, any physician who sees a registered ED patient may use the ED codes. A specialist called down for a Medicare patient reports 99281 to 99285. Medicare stopped paying consultation codes in 2010.
That’s the practical answer to the ER consult CPT code question. Our guide to ED consults for Medicare covers the inpatient consult codes too.
Not on the professional claim. Triage alone isn’t an evaluation and management service, so when a nurse triages a patient who then leaves without being seen (LWBS), the chart doesn’t support the 99281 CPT code. The hospital’s facility claim follows separate CMS rules, and a few state Medicaid programs set their own triage policy.
The AMA addressed this at its CPT symposium. An AMA E/M expert said, “Triage is not an evaluation and management service, and so you cannot report this service.” She added that 99281 “does require evaluation and management,” even without a physician present. You can read the full exchange in the AMA’s E/M expert Q&A, published January 14, 2025.
For billers, the rule fits on a sticky note. A triage note with vitals and a chief complaint, followed by an LWBS disposition, gets no professional E/M charge.
Hospitals follow a different trail. In the 2011 OPPS rule, CMS let hospitals bill a visit code for triage-only patients under their own coding guidelines. A 2012 CMS FAQ then required hospitals to furnish outpatient visits incident to a physician’s service and under an order. ACEP reads that to exclude care a nurse gives under a standing order alone.
Diagnostic tests don’t have to meet the incident-to rule. If the hospital ran a test before the patient walked out, it can still bill that test on the facility claim.
State Medicaid programs can go the other way. Iowa Medicaid’s Informational Letter 2504-MC-FFS replaced 99211 with 99281 for ER triage services, effective February 1, 2024. Under Iowa Medicaid’s ED E/M guide, updated March 2026, one ED level pays per encounter, and modifier 25 doesn’t create a second payment for triage.
Rules differ by state, so check the Medicaid billing rules for every state you bill. Then set your hospital revenue cycle management charge rules so a triage-only encounter never posts 99281 by default, while a Medicaid program that pays for it still gets the code.
If your charge capture drops a 99281 on every triage, you need a rule fix, and coders can’t patch it one claim at a time. We build payer-specific triage rules into our medical billing for ED groups, so a level 1 charge posts only where the payer recognizes it.
99281 is an ED visit for a minimal problem that may not need a physician present. 99282 is an ED visit where a physician or QHP documents a medically appropriate history or exam and straightforward MDM. 99211 is the office version of 99281, for established patients. The 99281 CPT code applies only inside a hospital ED.
The 99282 CPT code description requires “a medically appropriate history and/or examination and straightforward medical decision making.” That one clause puts a physician or QHP at the center of a level 2 visit. Level 1 doesn’t require one in the room.
| Feature | 99281 | 99282 | 99211 |
|---|---|---|---|
| Setting | Hospital ED, POS 23 | Hospital ED, POS 23 | Office or other outpatient site, such as POS 11 |
| Patient status | New or established | New or established | Established only |
| MDM | Doesn’t apply | Straightforward | Doesn’t apply |
| Physician or QHP presence | May not be required | Required: history or exam plus MDM | May not be required |
| Who reports it | Physician or QHP | Physician or QHP | Physician or QHP |
| Typical encounter | Nurse removes sutures under supervision | Physician evaluates one self-limited or minor problem | Nurse visit for an established office patient |
Report CPT code 99282 if a physician or QHP personally evaluates a self-limited or minor problem and the note supports straightforward MDM. A minimal service that clinical staff provide under supervision stays at 99281. ACEP expects few ED patients to fit level 1, so a physician group’s 99281 volume should stay small.
Undercoding here costs money on both claims. In 2026, Medicare pays a national $40.42 for CPT 99282 on the professional claim, $29.40 more than 99281. The hospital’s APC 5022 pays $156.87 against $86.15 for APC 5021. Billing 99281 after a physician documents straightforward MDM leaves both differences on the table.
The AMA treats these two codes as a pair. MDM doesn’t apply to either, and clinical staff may perform the face-to-face service for both. 99211 covers an office or other outpatient visit for an established patient, while 99281 covers an ED visit for any patient, new or established.
That’s why an urgent care center or hospital-based clinic reports 99211 for an established patient’s nurse visit, never 99281. Our 99211 billing guide covers the office-side supervision and co-billing rules.
Freestanding urgent care centers and physician offices can’t report the 99281 CPT code. CPT reserves 99281 to 99285 for a hospital emergency department, defined as an organized hospital-based facility for unscheduled episodic care that’s available 24 hours a day. Urgent care and office visits use office or other outpatient codes 99202 to 99215.
Payers read the place of service (POS) code on the professional claim to see where the visit happened, and the E/M code family has to match it. CMS defines POS 23 as “A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.”
| POS | CMS name | Visit codes on the professional claim |
|---|---|---|
| 23 | Emergency Room, Hospital | 99281 to 99285 |
| 20 | Urgent Care Facility | 99202 to 99215 |
| 11 | Office | 99202 to 99215 |
| 22 | On Campus-Outpatient Hospital | 99202 to 99215 (the hospital’s facility claim uses G0463) |
The CPT code for urgent care is an office or other outpatient visit, 99202 to 99215, billed with POS 20 and leveled by MDM or total time. Inside the ED, the CPT code for an ER visit is one of 99281 to 99285 with POS 23.
Some commercial contracts add a twist. A payer may pay a CPT code for an urgent care visit plus HCPCS S9088, an add-on for services in an urgent care center, or swap the visit for S9083, a global urgent care fee. Other payers treat both S codes as informational only. Neither is CPT, and neither is an ED code.
Hospital clinics on the main campus bill office codes with POS 22, and our POS 22 billing rules cover that setting. Registration matters as well. Under Medicare’s Claims Processing Manual (Chapter 12, section 30.6.11.C), a physician who meets an unregistered patient in the ED bills office or outpatient codes.
The HHS Office of Inspector General (OIG) tested this rule in OIG report A-07-23-05139, issued March 9, 2026. Auditors reviewed Medicare claims from 2021 and 2022 that carried ED visit codes with a non-ED place of service or revenue center.
Medicare improperly paid physicians $922,524 for 9,749 services. Hospitals received $14.2 million in potentially improper payments. CMS agreed to recover the $922,524 but didn’t concur with the other four recommendations, which included system edits.
In other words, a POS mismatch can still pay today and come back in a later review. Check POS 23 against ED registration on every 99281 to 99285 line before the claim goes out.
In 2026, Medicare pays a national $11.02 for the 99281 CPT code on the professional claim and $86.15 on the hospital’s facility claim under APC 5021, before geographic adjustment. The physician group and the hospital bill separately, so Medicare makes two payments for one level 1 ED visit, and the patient owes coinsurance on each.
CMS gives CPT code 99281 0.25 work RVUs and 0.33 total RVUs in the 2026 Medicare fee schedule. Multiply 0.33 by the $33.4009 conversion factor and you get $11.02, or $11.08 for qualifying APM participants at $33.5675. The amount stays small because the code has no direct practice expense inputs.
| Code | Total RVUs | 2026 Medicare national, professional | OPPS APC | 2026 Medicare national, facility |
|---|---|---|---|---|
| 99281 | 0.33 | $11.02 | 5021 | $86.15 |
| 99282 | 1.21 | $40.42 | 5022 | $156.87 |
| 99283 | 2.08 | $69.47 | 5023 | $278.89 |
| 99284 | 3.54 | $118.24 | 5024 | $426.30 |
| 99285 | 5.13 | $171.35 | 5025 | $608.43 |
Hospitals send their half on a UB-04 (837I) with an ED revenue code beside the CPT code. The rev code for emergency room services is 045X, and 0450 is the general classification line. If you searched for CPT code 0450, you were looking for that revenue code, which the National Uniform Billing Committee (NUBC) maintains outside CPT.
A hospital ED that isn’t open 24 hours a day, seven days a week counts as Type B and reports G0380 instead of 99281. Each hospital sets its facility level from internal guidelines, which CMS requires to match hospital resources to levels consistently, per ACEP’s APC payment FAQ.
The facility level and the physician’s level can differ for the same visit, so your hospital facility billing team should check both before the claims go out. All the figures above are national rates; local amounts move with the geographic practice cost index and the hospital wage index.
At 2026 national rates, Medicare allows $97.17 for a level 1 ED visit ($11.02 plus $86.15), and a patient who has met the deductible owes about $19.43. That splits into about $2.20 of coinsurance on the professional claim and about $17.23 on the facility claim, 20% of each.
The 2026 Part B deductible is $283. Until a patient meets it, they pay the Medicare-approved amount themselves. Medicare Advantage, commercial, and Medicaid patients pay under their own plan’s ED cost-sharing.
CMS set the 2026 conversion factor at $33.4009 for most clinicians, up 3.26%, and $33.5675 for qualifying APM participants, up 3.77%, per the 2026 fee schedule fact sheet. Both include a one-year 2.5% increase set by statute. Hospital OPPS rates rose 2.6%.
A separate 2.5% efficiency cut hit the work RVUs of non-time-based services. CMS left E/M services out of it, so 99281 kept its 0.25 work RVU.
Plan for a dip next year. CMS’s July 14, 2026 proposed rule would lower the conversion factors to $32.84 (down 1.68%) and $33.17 (down 1.19%) as the one-year increase expires. If RVUs hold, 99281 would pay about $10.84 in 2027. CMS publishes the final rule in early November in most years.
If your ED remittances don’t line up with these 2026 rates, our revenue cycle management services team can trace each short payment to the payer and the contract line behind it.
Payers deny or bundle a same-day 99281 CPT code because of the codes billed beside it. Check the suture removal add-ons and the surgical global period first. Then look for drug administration lines on the physician claim, which CMS’s National Correct Coding Initiative (NCCI) won’t pair with an ED visit.
CPT added 15853 (removal of sutures or staples not requiring anesthesia) and 15854 (removal of sutures and staples not requiring anesthesia) on January 1, 2023, as add-on codes reported with an E/M visit. ACEP’s surgical package FAQ calls them “not applicable for reporting services that occur within a hospital or emergency department setting.”
In the ED, the visit code carries the suture removal on its own. Bill 99281 when clinical staff remove the sutures under supervision, and leave the add-on codes off the claim.
Medicare dropped the 10-day global for simple repairs 12001 to 12018 on January 1, 2011, so our simple repair code 12001 guide lists a 0-day global. For Medicare, a later suture removal visit after a simple repair sits outside the repair’s payment, and you can bill it.
Intermediate repairs (12031 to 12057) and complex repairs (13100 to 13160) carry a 10-day global. If your group removes those sutures inside the 10 days, that’s post-op care. Report 99024 if the payer tracks post-op visits; it pays nothing.
Commercial payers that follow the CPT surgical package fold typical follow-up care into the repair, so check each payer’s global days before you bill the return visit. ACEP also notes that some groups skip billing the follow-up to spare patients a copay, which is a group policy choice.
In most cases, no. Modifier 25 marks a significant, separately identifiable E/M service on the same day as a procedure by the same physician or QHP. A level 1 visit that consists of the procedure itself, like a dressing change, has nothing separate to mark.
If a physician evaluates a separate problem and also performs a minor procedure, MDM sets the E/M level at 99282 or higher, and that line takes modifier 25. Our guide to modifier 25 on ED visits walks through that pairing.
Drug administration follows its own rule. Under the 2026 NCCI policy manual, Chapter XI, a physician can’t report 99281 to 99285 with drug administration codes such as 96360 to 96379. The one exception is drug administration at a separate encounter in a non-facility setting that day, with modifier 25 on the E/M code.
Hospitals paid under OPPS work differently. They may report drug administration with 99281 to 99285 and add modifier 25 to the visit code when it’s significant and separately identifiable. An intramuscular injection (96372) given in the ED belongs on the hospital’s claim, and the physician’s claim leaves it off.
The 99281 CPT code needs no MDM, so a level 1 note has to prove something else: the patient was a registered ED patient, and the problem stayed minimal. Check these seven items before the claim goes out.
On the hospital side, the facility level has to follow the hospital’s own internal guidelines. Keep the facility criteria worksheet with the record so an auditor can see how your coders chose the level.
Sample 99281 note: “Arrived 14:10, registered in ED. Here for suture removal, right forearm laceration repaired 7 days ago (simple repair, 4 sutures). RN removed 4 sutures; wound edges well approximated, no redness or drainage. Wound care instructions given. Supervising physician: [name]. Discharged 14:25. Dx: Z48.02.”
Payers deny the 99281 CPT code for a short list of reasons, and most of those denials come back to the place of service or a bundled same-day service. The table pairs each claim adjustment reason code (CARC) with its likely cause and the fix.
| CARC | Payer’s reason (paraphrased) | Likely cause on a 99281 claim | Fix |
|---|---|---|---|
| CO-5 | Code doesn’t match the place of service | 99281 billed with POS 11, 20, or 22 | Confirm ED registration and correct POS to 23, or recode to 99202 to 99215 |
| CO-58 | Service rendered in an inappropriate or invalid place of service | Payer doesn’t recognize the site as an ED | Appeal with the ED registration record, or recode to an office or outpatient visit |
| CO-97 | Payment included in another service already adjudicated | Visit falls inside a 10-day global or bundles with a same-day procedure | Check global days; add modifier 25 only for a separate, significant E/M; otherwise report 99024 or write it off |
| CO-236 | Code pair not allowed on the same day under NCCI | Drug administration (96360 to 96379) on the physician claim with 99281 | Remove the drug administration line from the professional claim; the hospital reports it |
| CO-185 | Rendering provider not eligible to perform the service | A nurse or other clinical staff member listed as rendering | Rebill under the supervising physician’s or QHP’s NPI |
| CO-16 | Claim lacks information or has a billing error | Missing rendering NPI, POS, or diagnosis | Add the missing field and send a corrected claim |
Track denials by CARC every month. A run of CO-5 denials points to a POS mapping error in your practice management system, and coders can’t fix that one claim at a time. Our guide to CMS-1500 claim errors shows where POS sits on the form, in item 24B.
Sorting by CARC also shows you which fixes belong upstream. Denial teams, ours included, start every review that way, and our denial management services team works each denial back to its root cause before the rebill goes out.
ClaimMax RCM runs emergency department billing for physician groups and hospitals. Our AAPC-certified coders level each visit from the 99281 CPT code to 99285 under the AMA’s 2023 rules. Before a claim goes out, the team checks POS 23 against registration, scrubs NCCI pairs, tests modifier 25 against the global period, and confirms the rendering NPI.
For pricing, ClaimMax RCM’s emergency department billing services cost 3.49% of collections, with insurance eligibility verification and prior authorization included. If a new ED physician, NP, or PA joins your group, credentialing and payer enrollment costs $120 per insurance.
If you’re comparing third-party medical billing companies, ask any vendor that quotes emergency room medical billing to walk you through four things. Get specifics on POS mapping, facility and professional claim splits, NCCI drug administration edits, and denial tracking by CARC. Our page on billing for ED physician groups shows how ClaimMax tracks denials and payments per provider.
A stack of CO-5 or CO-97 denials on your ED claims points to a fixable rule. Send us a sample through a free revenue cycle audit, and we’ll check it against the rules on this page.
99281 is the level 1 emergency department visit, for a patient whose problem may not need a physician or QHP present. Clinical staff can perform the service under supervision, but only a physician or QHP reports it. MDM and time don’t apply. In 2026, Medicare pays a national $11.02 on the professional claim and $86.15 on the facility claim.
No. A nurse can do the face-to-face work under supervision, but the AMA says only a physician or other QHP reports the service. Nurse practitioners and physician assistants count as QHPs, so they can report 99281 under their own NPI where state scope and payer enrollment allow. Medicare pays their services at 85% of the physician fee schedule amount.
99281 is the lowest ED level, for a minimal problem with no MDM requirement. 99285 is the highest and needs high MDM, such as an illness or injury that poses a threat to life or bodily function. At 2026 Medicare national rates, 99281 pays $11.02 professional and $86.15 facility, and 99285 pays $171.35 and $608.43.
Both. CPT makes no new or established distinction for ED codes 99281 to 99285, so any patient registered in the ED can qualify when the visit fits level 1. Its office counterpart, 99211, works differently and applies only to established patients seen in an office or other outpatient setting.
CPT code 99288 covers a physician’s or QHP’s direction of emergency medical systems (EMS) advanced life support, where the clinician directs ambulance or rescue crews by two-way voice communication. Medicare lists 99288 as a status B (bundled) code, so it doesn’t pay separately under the physician fee schedule. Commercial payers set their own policy for it.
Yes. 99281 is an active CPT code, and CMS prices it on the 2026 Medicare Physician Fee Schedule at 0.33 total RVUs. Its current descriptor took effect January 1, 2023, when the AMA replaced the old history, exam, and MDM requirements with today’s wording about physician presence.
Sources
The 76706 CPT code reports a real time ultrasound of the abdominal aorta, with image documentation, done to screen for abdominal aortic aneurysm (AAA). Medicare covers it once per lifetime for referred patients with a qualifying risk factor. Patients owe nothing when the provider accepts assignment.
What changed in 2026: CMS added the Z13.6 diagnosis pairing to its claims manual through Transmittal 13694, effective April 20, 2026. Rates reflect the CY 2026 Physician Fee Schedule.
AAA screening CPT code at a glance
| Field | Detail |
|---|---|
| Code | 76706 (CPT Category I, radiology section) |
| CMS short descriptor | Us abdl aorta screen AAA |
| In use since | January 1, 2017 (replaced HCPCS G0389) |
| Medicare frequency | Once per lifetime, at any provider |
| Required diagnosis pairing | Z13.6 plus a smoking code (Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219) or a family history code (Z84.89) |
| Modifiers | None for global billing; 26 or TC for split billing |
| Patient cost under Medicare | $0 with assignment; deductible and coinsurance waived |
| 2026 national rate | $105.88 national global, 2026 (non-QP, CMS Physician Fee Schedule) |
| Not for | Symptoms or a known aneurysm; use 76770, 76775, 93978, or 93979 |
You’ll see 76706 orders after wellness visits if you bill for a primary care, cardiology, or vascular practice. Each one is a small claim with strict rules. Medicare won’t pay it if one diagnosis code is wrong, the referral is missing, or another clinic screened the patient years ago.
Code 76706 is the CPT Category I code Medicare uses for a once per lifetime ultrasound screening of the abdominal aorta in patients at risk for abdominal aortic aneurysm. Groups authorized to perform covered diagnostic ultrasound can bill it, including radiology groups, vascular labs, cardiology practices, and hospital outpatient departments.
Per CMS Pub. 100-04, Chapter 18, Section 110.3.2, the long descriptor for 76706 matches the AMA wording, and CMS restated it in CMS Transmittal 13694 on March 19, 2026. Copy it word for word when you build the charge line in your billing system:
“Ultrasound, abdominal aorta, real time with image documentation, screening study for abdominal aortic aneurysm (AAA).”
CMS uses a short descriptor too: “Us abdl aorta screen AAA.” If you’re comparing the CPT code 76706 description against an order, three terms matter: screening, real time, and documentation. An order that says “rule out AAA” for a patient with back pain fails the first test.
A 76706 study has three parts: real time imaging of the abdominal aorta, a permanent record of the images, and a physician’s interpretation. CMS wrote the interpretation into the screening’s definition at 42 CFR 410.19, so you don’t report the read with a separate code.
Clinicians order it to find an enlarged aorta before it causes harm. Before you bill CPT code 76706, make sure the chart proves all three parts: stored images, the aortic measurement, and a signed report. A scan with no saved images won’t hold up if a payer asks for records.
The 76706 CPT code is the wrong choice when the patient has symptoms or a known aneurysm. Under 42 CFR 410.19, CMS defines the screening as a service for an asymptomatic individual, so a study ordered for back pain, a pulsatile mass, or a known AAA is a diagnostic exam.
Diagnostic aorta studies carry normal Part B cost sharing. CMS points them to 76770, 76775, 93978, and 93979, and the code comparison later in this guide shows how to pick one. Catch the problem at scheduling: if the order lists symptoms, ask the ordering office for a diagnostic order instead.
76706 replaced HCPCS code G0389 on Medicare screening claims starting January 1, 2017. CMS manual text still shows both: G0389 for dates of service from January 1, 2007 through December 31, 2016, and 76706 after that. Old quick reference PDFs that list G0389 alone are out of date.
The AMA added 76706 to CPT for 2017, and CMS retired G0389 once a CPT code covered the service. If your chargemaster or a payer grid still lists G0389, update it for current dates of service. Our guide to HCPCS vs CPT codes explains how the two code sets differ.
Medicare covers 76706 for a beneficiary who hasn’t had a prior AAA screening under Medicare, has a referral, and fits a risk category: a family history of AAA, or a man aged 65 to 75 who has smoked at least 100 cigarettes. That’s the rule in 42 CFR 410.19.
Medicare AAA screening coverage under the 76706 CPT code depends on five conditions. If one is missing, Medicare denies the claim, so check each before you schedule the scan. You’ll find most answers on the referral, and the prior screening answer in your MAC portal. Confirm the patient:
76706 has no single age limit under Medicare. The AAA screening age range of 65 to 75 belongs to one pathway: men who qualify through smoking history. A family history of AAA qualifies a man or woman at any Medicare age.
If a patient asks, “Is AAA screening only for men?” Medicare’s answer is no: women qualify through family history. Some guides send women or patients outside 65 to 75 to 76775 or 76770. That’s wrong. Code from the reason for the scan; Medicare checks the risk group for coverage.
Medicare eligibility matrix for 76706
| Patient | Medicare coverage under 76706 |
|---|---|
| Man 65 to 75 who has smoked at least 100 cigarettes | Eligible |
| Man 65 to 75 who never smoked and has no family history of AAA | Not eligible (the USPSTF Grade C recommendation doesn’t create Medicare coverage) |
| Man under 65 or over 75 who smoked and has no family history of AAA | Not eligible |
| Any man or woman with a family history of AAA | Eligible, no age limit |
| Woman who smoked and has no family history of AAA | Not eligible |
| Patient with a known AAA or AAA symptoms | Not a screening; bill the diagnostic code that matches the study |
42 CFR 410.19 adds a third pathway for other risk groups the USPSTF recommends, as specified through the national coverage determination process. Medicare.gov and Noridian list the two groups above and no others. Check with your MAC before you rely on that third clause for any patient.
Medicare pays for the 76706 CPT code once in a beneficiary’s lifetime, and a screening at any provider counts toward that limit. If a clinic in another state billed the screening years ago, Medicare will deny your claim, even if it’s your first visit with the patient.
Check prior use in your MAC’s provider portal before you schedule. Noridian’s portal supports 76706 eligibility checks; if you bill another MAC, look for the preventive services history in its portal. Pair that check with a Medicare benefit verification to spot Medicare Advantage enrollment.
A 76706 claim needs a referral, and since January 27, 2014, any physician or qualified nonphysician practitioner can write it. Before that date, the referral had to come out of the initial preventive physical exam (IPPE). CMS made the change in CMS Transmittal R3096CP.
Wellness visits remain a natural place to order the screening, since the provider is already reviewing family and smoking history with the patient. Our breakdown of annual wellness visit codes covers the IPPE (G0402), G0438, and G0439.
76706 costs the patient $0 when the provider accepts assignment, because Medicare waives the deductible and coinsurance for this screening. Medicare.gov’s coverage page states the same rule. Follow-up studies after a positive screen don’t get the waiver; they carry normal Part B cost sharing.
CPT 76706 needs two diagnosis codes on a Medicare claim: Z13.6 (encounter for screening for cardiovascular disorders) plus one risk code. Smoking history takes Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219; family history takes Z84.89. CMS put this pairing into its claims manual effective April 20, 2026.
76706 claims need Z13.6 plus one risk code from the table, matched to the patient’s pathway. The screening for AAA ICD-10 code is Z13.6, the general code for cardiovascular screening. There’s no separate ICD-10 code for AAA screening, so the second code carries the proof of risk.
Diagnosis codes CMS lists for 76706 (Pub. 100-04, Chapter 18, Section 110.3.2)
| Code | Description | Pathway |
|---|---|---|
| Z13.6 | Encounter for screening for cardiovascular disorders | Required on the claim |
| Z87.891 | Personal history of nicotine dependence | Smoking |
| F17.210 | Nicotine dependence, cigarettes, uncomplicated | Smoking |
| F17.211 | Nicotine dependence, cigarettes, in remission | Smoking |
| F17.213 | Nicotine dependence, cigarettes, with withdrawal | Smoking |
| F17.218 | Nicotine dependence, cigarettes, with other nicotine-induced disorders | Smoking |
| F17.219 | Nicotine dependence, cigarettes, with unspecified nicotine-induced disorders | Smoking |
| Z84.89 | Family history of other specified conditions | Family history |
Link 76706 to Z13.6 and the risk code in the diagnosis pointer. Some billers hesitate to point an imaging line at a Z code, since diagnostic ultrasound needs a sign or symptom. A screening claim reverses that: Medicare wants the screening code plus the risk code, with no symptom code.
On March 19, 2026, CMS issued Transmittal 13694 (Change Request 14421) to add the 76706 diagnosis codes to Pub. 100-04, Chapter 18, Section 110.3.2. Both its effective date and its implementation date are April 20, 2026. CMS wanted the manual to match the MLN preventive services quick reference.
Z13.6 isn’t a new requirement. Noridian last updated its AAA screening page, which lists the same pairing, on February 16, 2026, about two months before the transmittal took effect. CMS also added a note to the manual that more ICD-10 codes may apply, with an instruction to contact your MAC.
One more check for the new fiscal year: the FY2027 ICD-10-CM update took effect October 1, 2026. Z13.6, Z87.891, the five F17.21x cigarette codes, and Z84.89 remain valid in that code set, so the April 2026 list still applies to current dates of service.
Medicare denies 76706 screening claims that carry any of these five diagnosis patterns. Two signal a diagnostic study, and three use codes CMS left off its list:
Some coding guides suggest Z82.49 as the family history of AAA ICD-10 code, since an aneurysm is a circulatory disease. CMS lists Z84.89 instead. Before you use Z82.49, get your MAC’s acceptance in writing; without it, report Z84.89 and keep the relative’s diagnosis in the note.
Tobacco codes cause trouble on other Medicare screening claims as well. Low dose CT for lung cancer screening pairs a screening code with smoking history codes in a similar way, and our guide to lung cancer screening code 71271 walks through those rules.
If your team keys these pairings by hand, one missing risk code is all Medicare needs to deny the claim. With our medical billing service, we build the Z13.6 pairing check into charge review, so it runs before the claim leaves your system.
The 76706 CPT code is for a screening study in a patient with no symptoms and no known aneurysm. A limited retroperitoneal ultrasound of the aorta is 76775, a complete retroperitoneal study is 76770, and a duplex scan with Doppler flow analysis is 93978 (complete) or 93979 (limited).
There’s no single CPT code for abdominal aortic aneurysm imaging. You choose by intent first, screening or diagnostic, and then match the technique on the report to one of the four diagnostic codes. Coders who skip the first step end up billing a surveillance scan as a screening.
76706 fits one row of the table: screening an eligible patient with no symptoms. Some orders say “US abdominal aorta” and nothing else, so check the notes before you assign a US abdominal aorta CPT code. Your CPT code for aortic ultrasound depends on the order’s reason and the technique.
Aorta ultrasound code decision table
| Clinical situation | Technique | Code |
|---|---|---|
| Asymptomatic screening of an eligible patient | Real time ultrasound with image documentation | 76706 |
| Known AAA follow-up or symptoms, limited view of the aorta | Limited retroperitoneal ultrasound | 76775 |
| Full retroperitoneal survey: kidneys, abdominal aorta, common iliac artery origins, and IVC | Complete retroperitoneal ultrasound | 76770 |
| Duplex of the full course of the aorta, IVC, or iliac vessels | Duplex scan with Doppler flow analysis, complete | 93978 |
| Duplex of one segment or one side | Duplex scan, unilateral or limited | 93979 |
CMS names the same four diagnostic codes in Pub. 100-04, Chapter 18, Section 110.3.2, beside the 76706 descriptor. If a payer questions your code choice, that manual citation and the clinical reason on the order are the two things to show them.
The 76706 CPT code describes a screening, and 76775 is a limited diagnostic ultrasound of the same area. Medicare covers 76775 when the diagnosis supports medical necessity under MAC policy. A scan to follow a known aneurysm is diagnostic: 76775 for a limited view, or 76770 for the full retroperitoneum.
Orders that read “US AAA screen” need the risk factor check before you attach the US AAA screening CPT code. You still code a screening order on an ineligible patient as 76706. Medicare will deny it as a statutory exclusion. Talk to the patient about cost before the scan.
76706 is a real time screening study, and 93978 and 93979 are duplex scans with Doppler flow analysis. 93978 covers the full course of the aorta, IVC, or iliac vessels, and 93979 covers one segment or one side. Both duplex codes need a diagnostic reason on the claim.
76706 vs duplex aorta codes
| Attribute | 76706 | 93978 | 93979 |
|---|---|---|---|
| Type of exam | Screening ultrasound | Duplex scan, complete | Duplex scan, unilateral or limited |
| Indication | No symptoms, no known AAA, Medicare risk factor | Known or suspected vascular disease | Known or suspected vascular disease |
| Technology | Real time imaging with image documentation | Imaging plus Doppler flow analysis | Imaging plus Doppler flow analysis |
| Coverage area | Abdominal aorta | Full course of the aorta, IVC, or iliac vessels | One segment or one side |
| Restriction | Once per lifetime under Medicare | Medical necessity | Medical necessity |
USPSTF calls abdominal duplex ultrasonography the standard approach for AAA screening. That clinical wording doesn’t change Medicare coding: if the order is a screening for an eligible patient, the claim goes out on 76706, even when the sonographer runs Doppler.
76706 is the AAA screening CPT code Medicare recognizes, and 76700 and 76705 are abdominal surveys. 76700 is a complete abdominal ultrasound, and 76705 is limited. Neither carries the preventive waiver under Medicare, though some commercial plans, such as Kaiser Permanente Washington, accept them for AAA screening.
Before you bill 76706 with another ultrasound on the same day, check the current CMS NCCI practitioner PTP file. Pair lists change each quarter, so pull the current file instead of trusting a saved spreadsheet. CMS’s NCCI page links to the current practitioner files.
The 76706 CPT code takes no modifier when one practice owns the ultrasound equipment and its own physician reads the study. Split it when two entities share the work: TC for the scan and 26 for the interpretation. CMS lists TC and 26 for 76706 in Pub. 100-04, Chapter 18.
No modifier needed: your practice owns the equipment, performs the 76706 scan, and has its own physician sign the read. That’s a global claim on the CMS-1500, with place of service 11 for an office setting.
Modifier needed: two entities split the work. One entity owns the equipment and bills TC for the scan, and the interpreting physician bills 26 for the read. Each of the two claims carries the same diagnosis pair.
Outpatient hospital work follows its own pattern. Hospitals bill the technical portion on a UB-04 under OPPS, with no TC modifier on the facility line, and the reading physician bills 76706-26 on a CMS-1500 with place of service 22 or 19.
Who bills 76706, on which form, with which modifier
| Arrangement | Who bills | Claim form | Modifier |
|---|---|---|---|
| Practice owns the machine; its physician reads | Practice | CMS-1500, POS 11 | None (global) |
| Hospital outpatient scan; outside physician reads | Hospital (technical portion, under OPPS) | UB-04 | None on the facility line |
| Hospital outpatient scan; outside physician reads | Reading physician | CMS-1500, POS 22 or 19 | 26 |
| Imaging center scans; outside physician bills the interpretation | Imaging center | CMS-1500 | TC |
| Imaging center scans; outside physician bills the interpretation | Reading physician | CMS-1500 | 26 |
Don’t send TC and 26 claims from the same entity for one scan; if you own both parts, bill the global code. Cardiology and vascular groups that read at hospital sites face this split on their hospital imaging, and our cardiology and vascular billing support covers both settings.
Echocardiography uses the same 26 and TC split, with the same office and hospital patterns. If your group bills echo too, our 93306 billing guide covers that code’s payer rules, audit risks, and denial fixes.
Some online code summaries list 33, 59, 76, 77, and 91 as modifiers for 76706. Of those, 59 can apply in narrow cases, and the rest don’t fit a screening ultrasound. Check this table before a claim goes out:
Modifiers to keep off a 76706 screening claim
| Modifier | Why it doesn’t fit 76706 |
|---|---|
| 33 | Noridian says not to add it to a code that its own description identifies as preventive, and the 76706 descriptor says “screening study.” |
| 59 or XU | Use it when the CMS PTP file pairs 76706 with the other code, the edit allows a modifier, and the chart shows a separate service. |
| 76 or 77 | Repeat procedure modifiers don’t fit a once per lifetime screening. |
| 91 | A repeat lab test modifier; it doesn’t apply to imaging. |
| GA, GY, or GZ | Liability modifiers; they belong on the claim when an ABN situation applies, covered in the denial section. |
Noridian’s modifier 33 guidance states the preventive rule in plain terms, and Noridian last updated that page on May 24, 2024. Some commercial plans publish their own modifier 33 rules, so check the payer’s preventive coding guide when you bill outside traditional Medicare.
Medicare’s 2026 national allowed amount for the 76706 CPT code is $105.88 global, from 3.17 total RVUs at the $33.4009 conversion factor. With the deductible and coinsurance waived, Medicare pays that full amount minus the 2% sequestration cut. Locality adjustments move it up or down.
Medicare pays the same national amount for 76706 in facility and nonfacility settings, because its practice expense RVUs match. Each figure in the table is national and unadjusted, for the global service and each component, at both 2026 conversion factors.
76706 2026 fee and RVUs (national, unadjusted)
| Component | RVUs (work / PE / MP) | Non-QP at $33.4009 | QP at $33.5675 | Paid after 2% sequestration (non-QP) |
|---|---|---|---|---|
| Global | 3.17 (0.54 / 2.58 / 0.05) | $105.88 | $106.41 | $103.76 |
| 26 | 0.77 (0.54 / 0.19 / 0.04) | $25.72 | $25.85 | $25.21 |
| TC | 2.40 (0.00 / 2.39 / 0.01) | $80.16 | $80.56 | $78.56 |
QP means qualifying APM participant. CMS set both conversion factors in the CY 2026 PFS final rule (CMS-1832-F). Confirm the component split and your locality’s numbers in the CMS PFS Look-Up Tool before you load your fee schedule.
Your 76706 remittance won’t match the national figure to the cent. Five adjustments account for the gap, and knowing them keeps your team from appealing payments that are correct:
Hospitals bill the technical portion of 76706 under OPPS, so the physician fee schedule table doesn’t set their payment. Pull the 2026 APC and payment rate for 76706 from OPPS Addendum B before you quote a number to a hospital client.
For 2027, CMS proposed paying the physician fee schedule equivalent rate for imaging without contrast at excepted off-campus provider-based departments, with rural sole community hospitals exempt. Read the CY 2027 OPPS proposed rule and check whether 76706’s APC falls in that group once CMS finalizes it.
Commercial rates for 76706 come from your contracts, and they vary by plan and region. Each plan’s preventive cost sharing rules set what the patient owes, which can differ from the Medicare $0. Use your own remits and contract fee schedules instead of aggregator averages from the web.
A clean 76706 CPT code claim rests on four records: an order or referral from a physician or qualified nonphysician practitioner, a documented risk factor, a note that the patient has no symptoms, and a signed interpretation. NGS lists the order, the risk category, and asymptomatic status as required documentation.
Before the sonographer starts, the chart for a 76706 screening should hold five items. Your front desk can pull most of them from the referral and the MAC portal before the patient arrives:
The 76706 report should show real time imaging with stored images, the aortic finding with its measurement, and the reading physician’s signature and date. Under 42 CFR 410.19, the physician’s interpretation is part of the service, so an unsigned report means you can’t support the claim.
On a 76706 claim, the referring provider and the diagnosis pointers carry the screening rules. Enter the referring provider’s name in Box 17 and the NPI in Box 17b, and point the 76706 line to both Z13.6 and the risk code. Our clean claim requirements guide covers the rest.
RHCs and FQHCs have their own instructions in Pub. 100-04, Chapter 18, Section 110.3.4, titled “RHCs/FQHCs Special Billing Instructions.” If you bill from a clinic setting, read that section before you set up the 76706 charge, since clinic billing rules differ from the CMS-1500 process above.
Denials on the 76706 CPT code come from a short list of gaps, from a missing diagnosis pair to a screening the patient already used. Read the CARC and RARC first. Some denials need a corrected claim, and others need a different code or no rebill at all.
Match the denial on your 76706 remittance to the closest row, then confirm the fix against the CARC and RARC your MAC sent. MACs assign their own CARC and RARC pairs, so the codes in the second column show common patterns and may differ on your remit.
76706 denial patterns, causes, and fixes
| Denial pattern | Codes billers see | Root cause | Fix |
|---|---|---|---|
| Diagnosis pair missing or wrong | CO-11, CO-167 | Z13.6 alone, or Z82.49 or Z72.0 in place of a listed code | Corrected claim with listed codes, if the chart supports them |
| Screening already used | CO-119 | Prior screening under Medicare at any provider | Don’t rebill as a screening |
| Patient outside covered groups | Noncovered denial; RARC varies | No family history, or a smoker outside the men 65 to 75 group | Statutory denial; see the ABN rules below |
| Known AAA billed as screening | CO-11 | Surveillance study billed on 76706 | Rebill as 76775, 76770, 93978, or 93979 with a code from I71.40 to I71.43 |
| No referring provider | CO-16 | Box 17 left blank | Corrected claim with the referring provider’s name and NPI |
| Component mismatch | CO-4 | TC or 26 on the wrong claim, or global billed when the hospital took the technical portion | Rebuild the claim to match the modifier table |
| Same day bundling | CO-97 | Pair appears in the PTP edits | Check the PTP file; use a modifier where the edit allows one |
NGS’s December 2024 training classifies a second 76706 screening, or any other unmet statutory criterion, as a statutory (technical) denial rather than a medical necessity denial. If prior screening is unclear but the other requirements are met, the NGS preventive services training says to issue the ABN.
On the claim, you show who carries the financial liability with one of three modifiers, and each one has a narrow meaning:
CMS covers ABNs for this benefit in Pub. 100-04, Chapter 18, Section 110.3.3. Confirm the modifier with your MAC before you bill the patient; the wrong one can make your practice liable. Our A1c guide shows ABN modifiers GA and GZ on lab claims with frequency limits.
The two denials NGS lists as common for 76706, a missing referral and a second screening, both start before the scan. NGS stopped giving eligibility details, preventive history included, through its IVR on November 18, 2024, so your staff needs the portal for that check.
Add two more steps to the intake call. Confirm whether the patient has switched to Medicare Advantage, and ask the ordering office to state the risk factor in the order. Our guide to eligibility checks before scheduling covers the rest of the front desk work.
If 76706 denials keep coming back with the same CARC, the fix sits upstream at scheduling. Our denial management services team traces each pattern to its source and corrects the intake workflow along with the claim.
Outside traditional Medicare, the 76706 CPT code follows each payer’s policy. Medicare Advantage plans can’t charge cost sharing for Medicare preventive services in network. Most ACA plans cover the USPSTF Grade B group, men 65 to 75 who ever smoked, at $0 in network. TRICARE covers that same group.
Under 42 CFR 422.100(k), Medicare Advantage plans can’t charge deductibles, copays, or coinsurance for Medicare preventive services in network, and the 76706 CPT code falls in that group. Plans still run their own edits and network rules, so pull the plan’s preventive policy before you schedule.
Commercial coverage for 76706 traces back to the USPSTF. Under ACA Section 2713, plans that aren’t grandfathered must cover USPSTF Grade A and B services with no cost sharing in network. The USPSTF aortic aneurysm screening recommendation gives Grade B to men 65 to 75 who have ever smoked.
USPSTF AAA screening grades (December 10, 2019)
| Population | USPSTF grade | What it means for coverage |
|---|---|---|
| Men 65 to 75 who have ever smoked | B | ACA plans cover one screening with no cost sharing in network |
| Men 65 to 75 who have never smoked | C | Selective offer; no ACA mandate |
| Women who have never smoked and have no family history of AAA | D | USPSTF recommends against screening |
| Women 65 to 75 who have ever smoked or have a family history of AAA | I | Evidence insufficient; no ACA mandate |
The USPSTF recommendation dates to December 10, 2019, and it’s still the current final version. There’s no “USPSTF code” for billing: ACA coverage follows the grade, and 76706 is the code you bill. HealthCare.gov’s preventive care list includes one AAA screening for men of specified ages who have ever smoked.
If PR-1 shows up on a 76706 claim, the payer applied the deductible, a sign of diagnostic processing or a plan without the preventive mandate. Check the diagnosis pointers and the payer’s preventive code list first. Our guide to PR-1 deductible denials explains how payers apply that adjustment.
Commercial and military payers write their own 76706 rules. Aetna CPB 0702 and TRICARE’s AAA coverage page both limit screening to men, and some plans accept more codes than Medicare does. Compare them before you schedule a patient who isn’t on traditional Medicare.
76706 payer policy comparison
| Payer | Who qualifies | Codes listed | Diagnosis codes | Policy date |
|---|---|---|---|---|
| Medicare (traditional) | Family history at any age, either sex; men 65 to 75 who smoked at least 100 cigarettes | 76706 | Z13.6 plus Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219, or Z13.6 plus Z84.89 | Effective April 20, 2026 |
| Aetna CPB 0702 | Men 65 and older, one time | 76706 | Z13.6, Z87.891, and F17.210 to F17.219 as Aetna lists them | Last reviewed December 19, 2025 |
| Kaiser Permanente Washington (commercial) | Men in the USPSTF ever smoked group | 76706, 76700, 76705, 76770, 76775 | Z13.6, Z87.891, and the F17.21x cigarette codes | Revised August 14, 2026 |
| TRICARE | Men 65 to 75 who have ever smoked, one time | Not listed on the coverage page | Not listed on the coverage page | Updated September 16, 2024 |
Aetna won’t cover a woman with a family history whom Medicare would cover, and Kaiser Washington accepts five codes where Medicare accepts one. Keep Medicare rules off commercial claims, and check the payer’s policy date before each new plan year.
Medicaid coverage for 76706 varies by state, from the codes accepted to the age and risk rules. Check your state’s provider manual or fee schedule, and see our guide to state Medicaid billing rules for the enrollment and claim basics.
Once the 76706 screening shows an aneurysm, later aorta studies are diagnostic. Code each one by technique: 76775, 76770, 93978, or 93979, paired with I71.40 to I71.43 for an unruptured AAA. Expect normal Part B cost sharing, since the screening waiver doesn’t carry over to these studies.
For each surveillance scan after 76706, choose the CPT code for ultrasound of abdominal aorta by the technique the order calls for. The I71.4x codes describe location: I71.40 is unspecified, I71.41 is pararenal, I71.42 is juxtarenal, and I71.43 is infrarenal, all without rupture.
Follow-up aorta studies after a positive screen
| Follow-up study | Code | Diagnosis |
|---|---|---|
| Limited retroperitoneal ultrasound of the aorta | 76775 | I71.40 to I71.43 |
| Complete retroperitoneal ultrasound | 76770 | I71.40 to I71.43 |
| Full course duplex of the aorta, IVC, or iliac vessels | 93978 | I71.40 to I71.43 |
| Duplex of one segment or one side | 93979 | I71.40 to I71.43 |
Follow-up timing after a positive 76706 screen comes from clinical guidelines, and your job is to match each order to the right code. VA’s AAA screening guidance sets these intervals by size:
USPSTF notes that surgical repair is standard for men with an AAA of 5.5 cm or larger, or larger than 4.0 cm with 1.0 cm of growth in a year. Each surveillance scan needs its own order and an I71 diagnosis, and none of them go on 76706.
If imaging after 76706 moves to CT angiography, the codes are 74174 for CTA of the abdomen and pelvis or 74175 for the abdomen alone. Ultrasound stays the screening tool because CT adds radiation and contrast, and our CT abdomen and pelvis codes guide covers the wider CT code family.
Run these seven checks before any 76706 CPT code claim leaves your system. Most of them match a row in the denial table, so a miss here shows up later as a CARC on your remit.
If your team runs these checks by hand on each preventive claim, that’s work a billing partner can take off your plate. With our revenue cycle management services, we build the checks into scheduling and charge review.
Providers use 76706 to bill a screening ultrasound of the abdominal aorta for AAA, done in real time with image documentation and a physician’s interpretation. It’s for patients with no symptoms and no known aneurysm. Medicare covers it once per lifetime for referred beneficiaries who meet the risk criteria.
Ultrasound screening for AAA uses 76706, which replaced HCPCS G0389 for Medicare on January 1, 2017. If symptoms or a known aneurysm prompted the study, it isn’t a screening, so bill 76775, 76770, 93978, or 93979 based on the technique. Check the diagnosis pair before you submit.
For 76706, Medicare wants Z13.6 plus a risk code: Z87.891, F17.210, F17.211, F17.213, F17.218, or F17.219 for smoking history, or Z84.89 for family history. CMS wrote this AAA screening ICD-10 pairing into its claims manual effective April 20, 2026. Commercial plans publish their own lists.
Yes, Part B covers 76706 once per lifetime when the patient has a referral and a risk factor: a family history of AAA, or a man 65 to 75 who has smoked at least 100 cigarettes. The patient pays nothing when the provider accepts assignment.
76706 is a preventive code: its descriptor calls it a screening study, and Medicare pays it as a preventive service with the deductible and coinsurance waived. Noridian says not to add modifier 33 to codes that already identify the service as preventive, though some commercial plans set their own rules.
Medicare’s 65 to 75 window for 76706 applies to men who qualify through smoking history. Men and women with a family history of AAA qualify at any age once they’re on Medicare. Commercial plans differ: Aetna, for example, covers men 65 and older.
Medicare pays for 76706 once per lifetime. If the patient already had an AAA screening under Medicare at any provider, a second claim gets a statutory denial. Check prior use in your MAC portal before scheduling, and issue an ABN when you can’t confirm the patient’s screening history.
Your code depends on why the provider ordered the study: screening an eligible patient is 76706. A limited aorta study for symptoms or a known aneurysm is 76775, a complete retroperitoneal study is 76770, and a Doppler duplex is 93978 (complete) or 93979 (limited).
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CPT code 99308 reports a subsequent nursing facility visit with low medical decision making (MDM) or at least 20 minutes of total time on the date of the encounter. You bill it once per day, after the initial visit, for a resident of a skilled nursing facility or nursing facility.
Plenty of billing templates still carry the 2023 threshold of 15 minutes, and some guides still teach the component-based rules CPT retired in 2023. Payment changed too. In 2026, Medicare’s national rate for 99308 is $78.83 at POS 32 and $67.80 at POS 31, a gap of $11.03 per visit.
| Field | Value |
|---|---|
| Category | E/M, subsequent nursing facility care, per day (99307 to 99310 family) |
| Medical decision making | Low |
| Time requirement | 20 minutes or more of total time on the date of the encounter (since January 1, 2024) |
| Frequency | One subsequent nursing facility visit per patient, per practitioner, per date of service |
| Place of service | 31 (SNF, Part A stay) or 32 (NF, or SNF without Part A) |
| 2026 Medicare national rate | $78.83 at POS 32, $67.80 at POS 31 (non-QP) |
| Prolonged services add-on | None for 99308 |
| Telehealth | Allowed (POS 02, modifier 95, paid at the facility rate); no frequency cap since January 1, 2026 |
| CMS short descriptor | SBSQ NF CARE LOW MDM 20 |
| Look-alike code | 93308 (limited echocardiogram) |
In the 99308 CPT code description, the AMA lists the code as the second of four subsequent nursing facility care levels in the E/M section, 99307 to 99310. CMS shortens the rule to “SBSQ NF CARE LOW MDM 20,” meaning subsequent nursing facility care with low MDM or 20 minutes.
Read the descriptor line by line and you’ll find two layers. Each 99308 visit needs a medically appropriate history, exam, or both. From there, the level comes from low MDM or from at least 20 minutes of total time on the visit date.
A visit counts as subsequent once the resident has received any professional service from you during the current stay. Services from a colleague in your group with the exact same specialty and subspecialty count too. New or established patient status doesn’t change anything here.
If the facility discharges and readmits the resident, your first visit of the new stay goes back to the initial nursing facility codes. Across the skilled nursing facility CPT codes, initial care runs 99304 to 99306 and discharge day uses 99315 or 99316. CPT deleted the old annual assessment code, 99318, in 2023.
The initial visit is the full intake workup, and 99308 covers the check-ins after it. CPT applies the same nursing facility CPT codes in psychiatric residential treatment centers and ICF/IID settings. Settle the visit type first. Then score MDM inside the right group of nursing home E/M codes.
CPT 99308 requires at least 20 minutes of total practitioner time on the date of the encounter when you select the level by time. Nineteen minutes won’t carry it. The AMA raised the threshold from 15 minutes effective January 1, 2024, and that change still trips up billing teams today.
Two references back up the current CPT code 99308 description. AAFP’s E/M time table lists 99308 at low MDM or 20 minutes. AAPC’s 99308 code history logs the change on January 1, 2024, and shows 15 minutes as the prior wording.
Total time covers the work you do yourself for that resident on that date, at the bedside and away from it. Clinical staff time stays out of the count, and so does time on any service you report with its own code.
Travel and general teaching don’t count, and neither does work on another date. You also need the full 20 minutes. CPT’s E/M guidelines say the stated time must be met or exceeded, so the midpoint rule that rounds up some timed codes doesn’t apply.
One statement of total minutes in the note does the job. A typical line reads: “Total time on this date: 22 minutes, including chart review, exam, and a talk with the charge nurse.” CPT doesn’t require start and stop times, though some commercial payers still ask for them in their contracts.
Drop one older rule from your templates. Before 2023, you could pick a level by time only when counseling filled more than half the visit. CPT removed that condition on January 1, 2023, and some online answers still repeat it.
Table: 99308 time threshold history
| Period | How you select the level | Time threshold | Status |
|---|---|---|---|
| Before 2023 | Two of three components: expanded problem focused interval history, expanded problem focused exam, low MDM | About 15 minutes “typical,” usable only when counseling dominated | Retired |
| January 1, 2023 to December 31, 2023 | Low MDM or total time | 15 minutes, met or exceeded | Superseded |
| January 1, 2024 onward | Low MDM or total time | 20 minutes, met or exceeded | Current in 2026 |
You’ll find the old number in three kinds of sources. Google still ranks descriptor PDFs from 2023. CGS, a Medicare contractor, still hosts a 2013 checklist for 99308 that describes 15 minutes at the bedside.
The third source carries more weight. CMS’s CY 2026 Physician Fee Schedule final rule repeats older descriptor wording for the subsequent nursing facility codes in its telehealth section. That passage lists 99308 at 15 minutes. CMS wrote it to set telehealth frequency policy, and the AMA’s CPT code set still governs the time threshold.
CMS’s own 2026 short descriptor ends in “20,” and AAFP’s current table agrees. If a source lists 15 minutes for 99308, it’s quoting the 2023 descriptor. Fix any note template or charge sheet your team built before January 2024 so the threshold reads 20.
Then check your own claims. Pull the 99308 claims you’ve billed by time since January 2024 and look for notes showing 15 to 19 minutes. Unless the MDM in those notes supports low, the time supports 99307, and you’ll want to correct those claims before an auditor finds them.
Low MDM for CPT code 99308 means at least two of the three MDM elements reach the low level. The elements are the problems you address, the data you review, and the risk of your management plan. You still document a medically appropriate history and exam, but those no longer set the level.
CMS’s E/M Services guide explains how the AMA scores each element. Score the note in front of you, and two elements at low or higher give you low MDM. The third element can sit lower without pulling the visit down.
| Element | What counts as low | Nursing facility example |
|---|---|---|
| Problems addressed | Two or more self-limited or minor problems, one stable chronic illness, one acute uncomplicated illness or injury, or one stable acute illness | A check on hypertension that’s at goal |
| Data reviewed and analyzed | Limited: two items from outside notes reviewed, unique test results reviewed, and unique tests ordered, or an assessment that needs an independent historian | Reviewing a BMP result and an outside cardiology note |
| Risk of patient management | Low risk of morbidity from more testing or treatment | Continuing the current plan with routine monitoring |
Watch the word stable. Under the AMA’s definitions, a chronic illness counts as stable only when the resident is at their treatment goal. A resident whose blood pressure sits above goal has a chronic illness with progression, and that moves the problem element up to moderate.
A true 99308 can still include a prescription. Picture a resident with an uncomplicated UTI: you order a urinalysis and start an oral antibiotic. The problem scores low, the data scores minimal, and the prescription scores moderate risk. With two elements at low or higher, the visit supports 99308.
Two common patterns push a visit past low. A moderate problem includes two or more stable chronic illnesses, or one chronic illness that’s getting worse. Prescription drug management counts as moderate risk, and the pair together gives you moderate MDM and 99309, even under 30 minutes.
Take a resident with diabetes and hypertension whose antihypertensive dose you raise. Under skilled nursing facility coding guidelines built on the AMA’s MDM table, that visit supports 99309. Billing it as 99308 costs you $30.73 per visit at POS 31 and $35.74 at POS 32, using 2026 non-QP national rates.
The opposite mistake shows up too. A note that reads “stable, continue current plan,” with no data reviewed and no risk documented, supports 99307 at best. Reviewers downcode those notes on audit, and the fix sits in the template, which should prompt for problem status, data reviewed, the decision, and its risk.
If last month’s nursing facility claims show prescription changes coded as 99308, check whether the same notes address two chronic illnesses. Each match is about $31 left unbilled at POS 31. ClaimMax’s medical billing services begin with a free revenue cycle audit, which can surface this pattern before your next batch goes out.
CPT 99308 sits one level above 99307 and one below 99309 in the subsequent nursing facility family. All four codes share the same setting and the same daily limit. The MDM level and the time threshold separate them: 10 minutes for 99307, 20 for 99308, 30 for 99309, and 45 for 99310.
Table: Subsequent nursing facility levels at a glance (2026)
| Code | MDM level | Time (met or exceeded) | Typical nursing facility scenario | Prolonged add-on |
|---|---|---|---|---|
| 99307 | Straightforward | 10 min | Routine check where nothing changes | None |
| 99308 | Low | 20 min | One stable chronic illness, or one minor acute problem | None |
| 99309 | Moderate | 30 min | A worsening chronic illness, or two chronic illnesses with a prescription change | None |
| 99310 | High | 45 min | An unstable resident, or a decision about hospital transfer | 99418 (CPT) or G0317 (Medicare) |
Low MDM or 20 minutes supports 99308, while 99309 needs moderate MDM or 30 minutes. The usual tipping point is a moderate problem paired with prescription drug management. Picture a resident with COPD and heart failure whose diuretic dose you raise after a weight gain. That visit reaches 99309 even if it runs under 30 minutes.
Code 99307 covers straightforward MDM or 10 minutes, such as a visit where the resident is stable and you change nothing. Manage a minor acute problem in that same visit, like constipation treated with an over-the-counter laxative, and the work supports 99308. The problem and the risk both reach low.
If you select CPT code 99308 or its siblings by time, the minutes map onto the ladder: 10 supports 99307, 20 supports 99308, 30 supports 99309, and 45 supports 99310. The 99308 CPT code has no prolonged add-on of its own, so extra minutes raise the level instead.
Prolonged time attaches only to 99310. Under CPT, you add 99418 once total time reaches 60 minutes. Medicare doesn’t pay 99418 and uses G0317, starting at 85 minutes and counting time from the day before the visit through three days after. Our guide to prolonged service codes covers the office version.
Code by whichever method supports the higher level. A visit with low MDM and 32 documented minutes bills as 99309 by time, and a 15-minute visit with moderate MDM bills as 99309 by MDM. You don’t need to document time when MDM carries the level.
Bill CPT code 99308 with POS 31 when the resident is in a Medicare Part A SNF stay, and with POS 32 when the resident is in a nursing facility or in an SNF stay that Part A isn’t paying. Telehealth visits use POS 02 instead.
The skilled nursing facility POS follows the resident’s coverage on the date of service. POS 31 is the place of service code for a skilled nursing facility stay that Part A covers. Once Part A stops paying, the same resident in the same bed takes POS 32 on your next claim.
Table: Choosing POS 31 or POS 32 for 99308
| If the resident on the date of service is… | POS | 2026 national rate for 99308 (non-QP) |
|---|---|---|
| In a Medicare Part A covered SNF stay | 31 | $67.80 |
| A long-term nursing facility resident, past the 100 covered days, or in an SNF stay Part A doesn’t cover | 32 | $78.83 |
| In a dual-certified facility with Part A status unconfirmed | 31, until you verify Part A won’t pay | Rate for the row that applies |
CMS MLN Matters MM13767 describes the edit behind most POS 32 rejections. Since July 2025, Medicare rejects a professional claim with POS 32 when it overlaps a covered Part A SNF stay already on file. Claims that paid before the facility’s stay posted get adjusted.
The 2026 fee schedule made the choice costlier. CMS cut practice expense for facility settings, so POS 31 now pays $11.03 less than POS 32 for the same visit. PALTmed’s 2026 POS analysis puts that gap at about 14%.
Get Part A status from the facility’s census or MDS coordinator before each rounding day. Day 101 of a benefit period flips the resident from POS 31 to POS 32. Hospital returns need a recheck too, because a qualifying readmission can restart Part A coverage and move that resident back to POS 31.
Some guides still list POS 33 for 99308. Since 2023, assisted living (POS 13), group homes (POS 14), and custodial care facilities (POS 33) use the home and residence codes, with 99347 to 99350 for established residents.
Hospital inpatient and observation stays, LTACHs included, use 99221 to 99223 and 99231 to 99233. Office POS 11 doesn’t fit either. CPT’s nursing facility codes do apply at POS 54 (ICF/IID) and POS 56 (psychiatric residential treatment centers).
Part A status lives in the facility’s system, and that gap is where most POS errors start. ClaimMax’s revenue cycle management team builds a census check into charge entry, so your nursing home billing doesn’t rely on guesswork.
For CPT 99308, Medicare pays one subsequent nursing facility visit per patient, per practitioner, per date of service. Past that daily limit, frequency follows medical necessity and the federal visit schedule. Medicare sets no weekly cap, though some Medicaid and commercial plans do, so check the plan before you schedule routine rounds.
Federal nursing home rules at 42 CFR 483.30 set a minimum physician visit schedule for each resident, and the follow-up visits in that schedule bill as 99307 to 99310. A visit counts as timely if it happens no later than 10 days after its due date.
A mandated visit that also manages a medical problem is still one E/M claim. The CPT code for an annual nursing facility visit is no longer 99318, which CPT deleted in 2023. You bill whichever of 99307 to 99310 the work supports.
In an SNF, the physician performs the initial visit. After that, a nurse practitioner, physician assistant, or clinical nurse specialist can alternate the required visits with the physician, at the physician’s option. Medically necessary visits between those dates bill on their own merits.
Practitioners in the same group with the same specialty count as one provider. If two of them see the resident on one date, you submit one claim and take the level from the combined work. Different specialties, such as psychiatry and internal medicine, can each bill when both visits are medically necessary.
Picture two NPs from your group rounding on the same floor Monday, and both drop a 99308 for the same resident. One claim pays. The other denies as a duplicate or pays and turns into a recoupment later, since CMS RAC issue 0061 targets excess units of nursing facility visits.
A consultant’s first visit follows separate nursing facility consult rules, and the consultant’s follow-up visits use 99307 to 99310. Groups with several rounding providers need a same-day duplicate check before claims go out, and it’s one of the first edits worth building into group practice medical billing.
In 2026, Medicare’s national rate for CPT 99308 is $78.83 at POS 32 and $67.80 at POS 31 for clinicians paid at the standard conversion factor of $33.4009. Your actual payment shifts with your locality and provider type, and Qualifying APM Participants (QPs) get a higher conversion factor.
Table: 2026 Medicare national rates for 99308 (national, before geographic adjustment)
| Setting | POS | Total RVUs | 2026 non-QP rate (CF $33.4009) | 2026 QP rate (CF $33.5675) | 2025 rate |
|---|---|---|---|---|---|
| Nursing facility, or SNF without Part A | 32 (non-facility rate) | 2.36 | $78.83 | $79.22 | $71.81 |
| SNF, Part A stay | 31 (facility rate) | 2.03 | $67.80 | $68.14 | $71.81 |
| Telehealth, resident in the facility | 02 (facility rate) | 2.03 | $67.80 | $68.14 | $71.81 |
The gap between the two settings is new for 2026. Nursing facility codes used to carry the same practice expense in both settings, and the 2026 rule changed that. Compared with 2025, the POS 32 rate rose 9.8% and the POS 31 rate fell 5.6%. PALTmed’s table lists $79.22 at POS 32, which is the QP figure.
Table: 99308 RVU components (2026)
| Component | RVUs |
|---|---|
| Work | 1.30 |
| Practice expense, non-facility (POS 32) | 0.98 |
| Practice expense, facility (POS 31 and 02) | 0.65 |
| Malpractice | 0.08 |
| Total | 2.36 non-facility, 2.03 facility |
These values match the October 2026 release (RVU26D) in the CMS PFS relative value files. The table shows allowed amounts. Medicare pays 80% after the Part B deductible, and the resident or a secondary payer covers the rest.
For many long-stay residents, that secondary payer is Medicaid, because they’re dual eligible. State Medicaid billing rules decide how the crossover claim pays. NPs and PAs billing under their own NPI receive 85% of the fee schedule: $67.01 at POS 32 and $57.63 at POS 31 (non-QP).
Locality moves the number further. Using the 2026 GPCIs, 99308 at POS 32 runs from $72.91 in Arkansas to $101.46 in Alaska, and from $63.45 to $89.73 at POS 31. Medicaid, Medicare Advantage, and commercial plans pay by contract, and the MM13767 edit applies to Original Medicare claims.
Take a hypothetical group that bills 400 long-stay visits a month at POS 31 when POS 32 applies. That’s $4,412 a month left uncollected ($11.03 x 400). Track POS and payer mix each month in your RCM services reporting so a gap like that surfaces early.
CMS published the CY 2027 PFS proposed rule on July 16, 2026, and the final rule tends to come out in early November. PALTmed is pushing CMS to reverse the lower POS 31 payment. Check the final 2027 rates before you update charge masters or payer contracts in January.
CPT 99308 doesn’t need a modifier on a routine in-person visit. You add one only when something else applies: a same-day minor procedure (25), real-time video (95), a split or shared SNF visit (FS), or a resident on hospice (GV or GW).
The 99308 CPT code itself carries no modifier requirement, so each nursing facility modifier below answers a specific claim situation. Two of them, FS and the hospice pair, depend on where and why you saw the resident.
Table: Modifiers used with 99308
| Modifier | When it applies to 99308 | Watch for |
|---|---|---|
| 25 | A significant, separately identifiable visit on the same day as a minor procedure, such as debridement or I&D | The note must stand apart from the procedure’s own evaluation |
| 95 | Real-time audio and video telehealth | Pairs with POS 02 and doesn’t change payment |
| FS | A split or shared visit in an SNF (POS 31) | Not allowed on NF (POS 32) visits or on visits the physician must perform in full |
| GV | A hospice resident seen by an attending physician the hospice doesn’t employ or pay, for the terminal condition | Without it, the visit can deny as hospice-covered |
| GW | A hospice resident seen for a problem unrelated to the terminal condition | Name the unrelated problem in the assessment |
| 59 or XE, XP, XS, XU | Not used on 99308; CPT bars modifier 59 from E/M services | Put 59 on the procedure and 25 on the E/M |
| AI | Not used on 99308 | Belongs on 99304 to 99306 billed by the principal physician of record |
| CG | Not required on a 99308 professional claim | Skip it unless a payer policy names it |
CMS ended the telehealth frequency limit on subsequent nursing facility visits as of January 1, 2026, with no sunset date, according to the CMS telehealth FAQ. The written limit had been one telehealth visit per 14 days, and CMS had suspended it through 2025.
Bill POS 02 with modifier 95, and the visit pays the facility rate, the same $67.80 as POS 31 (non-QP). Our POS 02 telehealth billing guide and our modifier 95 rules cover both pieces in detail.
The facility can bill the originating site fee, HCPCS Q3014, which carries a 2026 fee schedule amount of $31.85. Medicare’s audio-only option covers patients in their homes, so a facility resident’s visit needs real-time video. A phone call can’t stand in for 99308, and CPT deleted the phone E/M codes 99441 to 99443 in 2025.
In an SNF, a physician and an NPP from the same group can bill a split or shared 99308 with modifier FS. The exception covers visits CMS requires the physician to perform in full, such as the initial SNF visit. CMS split or shared rules state that nursing facility visits can’t bill this way.
The billing practitioner is whoever performed the substantive portion. CMS defines that as more than half of the combined total time, or a substantive part of the MDM. A guide that bans split or shared billing in all nursing homes is out of date for SNF stays.
The CPT 99308 description sets the requirements, and your note has to prove each one. A clean note shows four things: the problems you addressed and their status, the data you reviewed, your management decision and its risk, and, for time-based coding, the total minutes for that date.
These seven items are the SNF billing guidelines for the 99308 notes your team writes. Build them into your note template, so the EHR prompts for each item before the provider signs and the coder can score MDM without guessing.
| Example: low-MDM 99308 note (de-identified)Subsequent NF visit, POS 32. Long-stay resident; no active Part A per facility census.Reason: nursing flagged one systolic reading of 148; 7-day average 128/76.Interval history: no headache, chest pain, or dizziness; amlodipine 5 mg daily per MAR.Exam: BP 130/78, HR 72, lungs clear, no edema.Data: reviewed BMP dated 9/28 (K 4.1, Cr 1.0) and outside cardiology note dated 9/20.Assessment: essential hypertension (I10), at goal, stable.Plan: continue amlodipine 5 mg; twice-daily BP checks; notify if systolic over 170.Total time on this date: 22 minutes, including chart and lab review, exam, discussion with the charge nurse, and documentation. |
Scoring the example: one stable chronic illness scores low, and two reviewed items give limited data. The decision to continue a prescription can score moderate risk, but problems and data both sit at low, so the MDM is low. On time alone, 22 minutes also supports 99308.
Table: Note phrases that invite downcoding
| Invites downcoding | Write instead |
|---|---|
| “Pt stable, continue meds” | “Hypertension at goal (7-day average 128/76); continue amlodipine 5 mg.” |
| “Labs reviewed” | “Reviewed BMP 9/28: K 4.1, Cr 1.0.” |
| “Spent time with patient” | “Total time on this date: 22 minutes (review, exam, nursing discussion, documentation).” |
Link each visit to the condition you managed. Common ICD-10 codes for skilled nursing facility visits include I10 (hypertension), E11.9 (type 2 diabetes without complications), J44.9 (COPD), N39.0 (urinary tract infection), and F03.90 (unspecified dementia). Check each one against the FY2027 code set, which took effect October 1, 2026.
Z51.89 means an encounter for other specified aftercare, and it doesn’t explain why you saw the resident. Putting it first in place of the treated condition is a common trigger for a CARC 11 denial. List the managed condition first and any Z codes after it.
Most CPT code 99308 denials trace back to five fixable causes: the wrong place of service, a second visit on the same day, documentation that doesn’t support low MDM, a missing or wrong modifier, and a diagnosis that doesn’t explain why you saw the resident.
Table: Common 99308 denials, causes, and fixes
| Denial | What it means | Usual cause on 99308 | Fix |
|---|---|---|---|
| CARC 5 | Procedure code inconsistent with the place of service | POS 11, 13, 21, or 33 on a 99308 | Correct the POS, or switch to the right code family |
| Rejection (CR 13767 edit) | Claim rejected before adjudication | POS 32 overlapping a covered Part A SNF stay | Resubmit with POS 31 after checking the census |
| CARC 18 | Exact duplicate claim or service | A second same-day visit from the same group and specialty | Combine the work on one claim and send changes as a replacement claim (frequency code 7) |
| CARC 50 | Not deemed a medical necessity by the payer | Level not supported, or a routine note with no active problem | Appeal with the note mapped to the MDM elements, or correct the level |
| CARC 11 | Diagnosis inconsistent with the procedure | An aftercare Z code listed without the treated condition | Recode with the condition you managed |
| CARC 4 | Procedure code inconsistent with the modifier, or a required modifier missing | Telehealth billed without 95, or FS on a POS 32 visit | Correct the modifier and resubmit |
| CARC 181 | Procedure code invalid on the date of service | 99318 left on an old template | Rebill with the right code from 99307 to 99310 |
| CARC 16 | Claim lacks information or has submission errors | Missing rendering NPI or service facility address | Complete the field and resubmit |
Sort these denials into two tracks. Data errors (CARC 4, 5, 11, 16, and 181) go out as corrected claims. Clinical disputes (CARC 50) go to appeal, with the note mapped to the three MDM elements and the total time if you coded by minutes.
A second same-day visit that got paid still counts as an overpayment. Refund it once you find it, before a recovery auditor does. Fixing the cause matters more than the single claim, since the same template or scheduling habit tends to repeat the error.
Facility staff sometimes assume the SNF bills your visit. Under the nursing home billing guidelines in the CMS SNF billing reference, physician services fall outside SNF consolidated billing, so your practice submits 99308 to Part B on its own claim.
If the same CARC keeps coming back on your nursing facility claims, the cause tends to sit in one step of the workflow. ClaimMax’s full-service medical billing team traces each denial back to that step and fixes it there.
The 99308 CPT code description covers a subsequent nursing facility visit, billed per day, with low MDM or at least 20 minutes of total time. CMS abbreviates it as “SBSQ NF CARE LOW MDM 20.” In plain words, it’s a follow-up visit for a resident you’ve already seen during the current stay.
Yes. An NP can bill 99308 under their own NPI where state scope of practice allows, and Medicare pays 85% of the fee schedule: $67.01 at POS 32 and $57.63 at POS 31 (non-QP). In an SNF, the physician performs the initial visit, and split or shared billing with modifier FS works in SNFs only.
No, not by one practitioner or by colleagues in the same group and specialty. Medicare pays one subsequent nursing facility visit per patient, per practitioner, per date. Add up the work from both encounters and bill one code at the level the combined MDM or total time supports, which may turn out to be 99309 or 99310.
No. The practitioner who discharges the resident reports 99315 (30 minutes or less) or 99316 (more than 30 minutes) for that day’s work, including the final exam and discharge paperwork. After the resident goes home, the community clinician who takes over may bill transitional care management codes for the 30 days that follow.
No. Since January 1, 2023, assisted living residents get the home or residence codes, 99347 to 99350 for established patients, billed with POS 13. That change retired the separate domiciliary codes. CPT code 99308 applies only to residents of an SNF, a nursing facility, an ICF/IID, or a psychiatric residential treatment center.
No new code replaced it. CPT deleted 99318 on January 1, 2023, so an annual nursing home visit now bills as whichever of 99307 to 99310 the MDM or total time supports. Keep that note focused on the problems you addressed, since the annual label alone doesn’t set the level.
No. The code carries global indicator XXX, so global surgery rules don’t apply to it. If you also perform a minor procedure that day, add modifier 25 to the visit when the E/M work is significant and separately identifiable from the evaluation that comes with the procedure itself.
CPT code 99308 pays in full when the note supports low MDM or clears the 20-minute floor. The claim side matters as much, because POS 31 versus POS 32 sets the rate and drives the CR 13767 rejections covered above.
If you’d like a second set of eyes on your nursing facility claims, ClaimMax RCM starts with a free revenue cycle audit. It’s a 20-minute working session on your actual billing data, with a custom report and zero obligation, so you can see where your nursing home billing stands before you change anything.
CPT 64721 is the open carpal tunnel release CPT code: the surgeon frees (neuroplasty) or moves (transposition) the median nerve at the carpal tunnel through an open incision that divides the transverse carpal ligament. It’s a unilateral code. The American Medical Association (AMA) added a third release code, 64728, on January 1, 2026.
On the claim, you pick the code from the surgical approach and the modifier from the operated side. Payment depends on the setting. Medicare pays the surgeon one rate in the office and a lower one in an ambulatory surgery center (ASC) or hospital outpatient department (HOPD), where the facility bills its own fee.
| Key takeawaysOpen release on one wrist: bill 64721 with RT or LT.Endoscopic release is 29848; an endoscopic case converted to open is 64721 only.Both wrists in one session: 64721-50, one unit, paid at 150% on Medicare physician claims.2026 national Medicare physician rate: $482.64 in the office, $423.19 in a facility.The 90-day global covers routine post-op visits, wound checks, and suture removal.New in 2026: 64728 for percutaneous balloon release; Anthem and Premera don’t cover it. |
Last verified: Centers for Medicare & Medicaid Services (CMS) CY 2026 Physician Fee Schedule, National Correct Coding Initiative (NCCI) Policy Manual (January 1, 2026), Medicare.gov Procedure Price Lookup (2026), and FY2027 ICD-10-CM.
Code 64721 carries a 090 global period, a 2026 work relative value unit (RVU) of 4.85, and a national Medicare physician payment of $482.64 in the office or $423.19 in a facility. Coders check the fields below before a carpal tunnel claim goes out.
64721 quick facts, 2026
| Field | Value |
|---|---|
| Description | Open release of the transverse carpal ligament to free or move the median nerve at the wrist |
| Procedure type | Open surgical release. Endoscopic is 29848; percutaneous with balloon dilation is 64728 (new January 1, 2026). |
| Global period | 090: 90 days after surgery, a 92-day window counting the day before and the day of surgery |
| Laterality | Unilateral; append RT or LT |
| Conversion rule | Endoscopic converted to open: report 64721 only |
| Bundling | 29848 on the same wrist, the surgeon’s local anesthesia, closing the incision (12001 to 13153), and supplies |
| Bilateral, same session | 64721-50, one unit, on a Medicare physician claim (bilateral indicator 1). The ASC bills two lines. |
| Medically Unlikely Edit (MUE) | One unit per day, adjudication indicator 2 |
| Multiple procedures | Indicator 2: 100% for the highest-valued code, 50% for the next |
| 2026 RVUs | Work 4.85; total 14.45 non-facility, 12.67 facility |
| 2026 physician payment (national) | $482.64 non-facility, $423.19 facility, at a $33.4009 conversion factor |
| 2026 facility payment (national) | ASC $948.66; HOPD $1,995.02 under ambulatory payment classification (APC) 5431 |
| Bilateral payment | 150% of the one-side amount |
| Assistant at surgery | Not paid by Medicare (indicator 1) |
| ICD-10-CM | Carpal tunnel syndrome (CTS): G56.01 right, G56.02 left, G56.03 bilateral |
| Add-on | +64727, internal neurolysis with an operating microscope |
CPT code 64721 reports an open carpal tunnel release (CTR): the surgeon divides the transverse carpal ligament through an incision in the palm and frees or repositions the median nerve at the wrist. It’s a unilateral surgical code in the Nervous System section with a 90-day global period, and you bill it once per wrist.
The AMA owns the CPT code set, and new and revised codes take effect each January 1. Our breakdown of CPT vs HCPCS codes covers who maintains which code set. The official long descriptor reads:
“Neuroplasty and/or transposition; median nerve at carpal tunnel.” CPT copyright American Medical Association.
Read in plain words, the CPT code 64721 description has three parts:
CMS fee schedule files list 64721 under the short descriptor “Carpal tunnel surgery.” Billing staff picked up that label, so you’ll hear 64721 called the carpal tunnel surgery CPT code.
Yes. The median nerve and nine flexor tendons run through the carpal tunnel, and the transverse carpal ligament forms its roof. If a coding exam asks you to code decompression of the median nerve at the wrist, palm side, the answer is 64721. Ulnar nerve releases have two codes of their own:
No, 64721 isn’t a pain management code. Hand surgeons, orthopedic surgeons, plastic surgeons, and neurosurgeons bill it. Pain management physicians bill the injection side of carpal tunnel care, such as 20526 for a therapeutic injection into the carpal tunnel.
Your practice’s carpal tunnel CPT code depends on the service. You report 20526 for an injection in the clinic and 64721 for the open release in surgery. Surgical claims carry global periods and bilateral rules on top of that, the kind of work our orthopedic medical billing team handles.
The 64721 CPT code belongs to a family of nerve decompression codes. Each one names a nerve and a site, so you code from the anatomy in the op note:
Nerve decompression codes related to 64721
| Code | Scope in plain language | Site |
|---|---|---|
| 64704 | Neuroplasty of a nerve of the hand or foot | Hand or foot |
| 64708 | Open neuroplasty of another major arm or leg nerve | Arm or leg |
| 64718 | Release or transposition of the ulnar nerve | Elbow (cubital tunnel) |
| 64719 | Release or transposition of the ulnar nerve | Wrist (Guyon’s canal) |
| 64721 | Open release or transposition of the median nerve | Wrist (carpal tunnel) |
| 64722 | Decompression of an unspecified nerve | Varies |
| +64727 | Internal neurolysis with an operating microscope (add-on) | Added to a neuroplasty code |
| 64728 | Percutaneous median nerve decompression with balloon dilation and ultrasound guidance (new in 2026) | Wrist (carpal tunnel) |
Payment for 64721 covers the whole open release: the incision, exposure and division of the transverse carpal ligament, external neurolysis of the median nerve, and closure. Medicare also counts the surgeon’s local anesthesia, surgical supplies, and routine post-op care through day 90 as part of the surgical package.
The operative report is the receipt behind the claim, so these six lines need to be in it:
Two of those lines carry the most weight. You’ll use the anesthesia line to decide whether anyone bills anesthesia on a separate claim. The incision line proves the open approach that separates 64721 from endoscopic release, and if an endoscope went in at any point, the note should say when and why.
Each item below has a written rule behind it:
Adding a repair code for the release incision is a habit worth breaking. For wound repairs that do bill on their own, see our notes on CPT 12001 repair rules.
Coding this case looks easy, and surgeons still disagree on it. In a 2021 hand surgery coding study published in the Journal of Hand Surgery Global Online, 421 American Society for Surgery of the Hand members coded an open carpal tunnel release. All of them included 64721, but 15.4% of responses added codes that three independent coders left off.
Some surgeons in that survey added 01810 for their own local anesthesia or 69990 for a microscope. The authors note that NCCI doesn’t allow payment for either code, so those extra lines come back as denials on a real claim.
The CPT code for carpal tunnel release depends on the approach in the operative report: 64721 for an open release, 29848 for an endoscopic release, and 64728, new on January 1, 2026, for a percutaneous release with balloon dilation and ultrasound guidance. Code from the op note, since a case booked as endoscopic can finish open.
CPT code carpal tunnel release comparison, 2026
| 64721 | 29848 | 64728 | |
|---|---|---|---|
| Approach | Open incision, direct view | Wrist endoscope | Percutaneous, with balloon dilation and ultrasound guidance |
| The op note must show | Open incision, ligament divided under direct vision, side | Endoscope used to divide the ligament, portals, side | Ultrasound guidance and balloon dilation, side |
| Global period | 090 | 090 | 000 |
| 2026 work RVU | 4.85 | 6.23 | 2.70 |
| 2026 Medicare surgeon fee, office | $482.64 | $485.65 | $1,343.05 |
| 2026 Medicare surgeon fee, facility | $423.19 | $485.65 | $122.58 |
| 2026 ASC facility fee | $948.66 | $872.87 | $1,201.96 |
| 2026 HOPD facility fee | $1,995.02 | $1,642.82 | $1,995.02 |
| Commercial coverage | Covered with medical necessity | Covered with medical necessity | Anthem: not medically necessary. Premera: investigational. |
Source: CMS Physician Fee Schedule (2026 national amounts, July 2026 data), July 2026 ASC Addendum AA, and July 2026 OPPS Addendum B.
Run the CPT carpal tunnel release decision through these steps, and stop at the first match:
[Image placeholder: Decision chart showing the five steps above. Alt text: “Release carpal tunnel CPT code decision chart: 64721, 29848, 64728”]
The approach is the difference. Paraphrased, the 29848 CPT code description reads as a surgical wrist endoscopy that releases the transverse carpal ligament, which makes 29848 the endoscopic carpal tunnel release CPT code. 64721 does the same release through an open incision.
CPT 29848 carries the higher work RVU in 2026 at 6.23, against 4.85 for the open release. In a facility, that puts the endoscopic surgeon fee about $62 ahead: $485.65 for 29848 and $423.19 for 64721. Pages that say the open release carries more work value have it backward for 2026.
Same wrist, same encounter: don’t bill both. Under the NCCI Policy Manual, Chapter VIII, 64721 includes 29848, and the PTP edit lists 64721 as column 1 and 29848 as column 2. The edit carries modifier indicator 1, so a documented separate site lets you bypass it.
Medicare pays both codes when the surgeon works on different wrists in one session. You’d bill 64721-RT and 29848-LT, because NCCI Chapter I recognizes RT and LT for procedures on different sites. CPT code 29848 needs a side modifier on its own claims too, since it’s a unilateral code that takes RT, LT, or 50.
NCCI Chapter VIII, Section C.13 (revised January 1, 2026) states: “If an endoscopic procedure is converted to an open procedure, only the open procedure may be reported.” The failed scope attempt gets no code and no distinct-procedure modifier.
On a converted case, the carpal tunnel release CPT code is 64721, whatever the surgery schedule said. The CTR CPT code follows the technique that finished the release. A surgeon who divides the ligament through an open incision and slides a scope in afterward to look has still done an open release.
Modifier 22 fits a conversion if the note shows far more work than a typical open release, such as added time, dense scar, or a longer dissection, compared against a normal case. Most payers review 22 claims by hand, so attach the op note and a line comparing the time to a routine case.
Code 64728 is the newest carpal tunnel code, effective January 1, 2026. The 64728 CPT code description, paraphrased, is percutaneous decompression of the median nerve at the carpal tunnel, with balloon dilation inside the tunnel and ultrasound guidance included. CMS gives it a 0-day global period, and the American Society of Plastic Surgeons (ASPS) reports the same.
In the office, 64728 pays $1,343.05 because its non-facility practice expense RVU is 37.27, against 0.73 in a facility, where the surgeon gets $122.58. Facilities collect $1,201.96 in an ASC, a device-intensive rate, and $1,995.02 in an HOPD.
Commercial plans treat it as a different CPT for carpal tunnel release with its own coverage rules. Anthem’s guideline CG-SURG-112 lists 64728 as not medically necessary. Premera policy 7.01.595 (effective July 1, 2026) lists ultrasound-guided percutaneous intracarpal tunnel balloon dilation release as investigational.
Check the patient’s plan and get written authorization before anyone books 64728. Our insurance eligibility verification team runs that check before the patient reaches the exam room.
CPT 64721 needs a side modifier on almost every claim because it’s a unilateral code: RT for the right wrist and LT for the left. Both wrists in one session take modifier 50 with one unit on Medicare physician claims. Modifiers such as 22, 51, 58, 59, and 79 apply when the case calls for them.
Claim lines for 64721 by side and setting
| Scenario | Physician claim | ASC facility claim | ICD-10-CM |
|---|---|---|---|
| Right wrist | 64721-RT | 64721-RT | G56.01 |
| Left wrist | 64721-LT | 64721-LT | G56.02 |
| Both wrists, same session | 64721-50, one unit (Medicare); some commercial plans want RT and LT lines | 64721-RT and 64721-LT, one unit each | G56.03 |
| First side of a planned staged bilateral case | 64721-RT | 64721-RT | G56.03 |
| Second side, inside the first side’s global period | 64721-58-LT if planned; 64721-79-LT if not | 64721-LT | G56.02 |
| Left endoscopic release | 29848-LT | 29848-LT | G56.02 |
On a right-side claim, the CPT code for right carpal tunnel release is 64721-RT; on a left-side claim, the CPT code for left carpal tunnel release is 64721-LT. The right carpal tunnel release CPT code and the left carpal tunnel release CPT code are one number, and the modifier alone tells the payer which wrist you treated.
For an open case on the right, the right open carpal tunnel release CPT code line reads 64721-RT with G56.01. A left endoscopic carpal tunnel release CPT code line reads 29848-LT with G56.02. Keep the side identical in four places: the op note header, the procedure narrative, the modifier, and the ICD-10 code for carpal tunnel release.
Medicare physician claims get one line, modifier 50, and one unit. The NCCI Policy Manual, Chapter I states: “If the bilateral surgery indicator is ‘1,’ a bilateral surgical procedure must be reported with ‘1’ unit of service and modifier 50.” 64721 carries that indicator.
CMS enforces it through the MUE. 64721 allows one unit per day with MUE adjudication indicator (MAI) 2, so two units on one line, or RT and LT on two lines, fail the edit on a Medicare physician claim. Chapter I, Section V says your Medicare Administrative Contractor (MAC) can’t override an MAI 2 edit on reopening or redetermination.
Put the charge for both wrists on the modifier 50 line. Medicare pays the lower of your total charge or 150% of the one-side fee schedule amount, so a one-side charge leaves money on the table. On the CMS-1500, Box 24G (units) reads 1; getting it wrong is one of the common CMS-1500 form mistakes on bilateral cases.
ASCs follow a different rule. The Medicare Claims Processing Manual, Chapter 14 has ASCs report a bilateral procedure “as two procedures, either as a single unit on two separate lines or with ‘2’ in the units field on one claim line.” First Coast, a Medicare contractor, rejects ASC claims billed with modifier 50.
Commercial plans vary. Some reject modifier 50 and want RT and LT lines, so check each payer’s bilateral policy before the claim drops. At ClaimMax RCM, coders match the side in the op note header, the narrative, the modifier, and the ICD-10 code before a hand surgery claim goes out.
In a staged case, the surgeon does the second wrist weeks after the first. Inside the 90 days, the modifier depends on the chart: 58 if the surgeon documented the staged plan at or before the first surgery, and 79 if the surgeon didn’t plan it. The CMS Global Surgery Booklet says a new post-op period starts with either one.
Your diagnosis coding changes too. Under Section I.B.13 of the FY2027 ICD-10-CM Official Guidelines, you report the bilateral code, G56.03, for the first side. For the second side, once the first side no longer has the condition, you switch to the one-sided code for the wrist still affected, G56.02 or G56.01.
If bilateral and staged releases keep coming back as duplicates or global-period denials, our orthopedic billing team can walk through your recent hand surgery claims with you and show which rule tripped each one.
The 64721 CPT code global period is 90 days, listed as 090 global days in the Medicare fee schedule. Medicare’s package covers the pre-op visit on the day before or the day of surgery, the release itself, and routine post-op care for 90 days, a 92-day window by CMS’s count.
Medicare pays these services as part of the surgical fee:
The CMS Global Surgery Booklet (MLN907166, December 2025) counts the total global period as 92 days: the day before surgery, the day of surgery, and the 90 days after.
In the 2026 fee schedule, 64721 splits into 11% pre-op, 76% intra-op, and 13% post-op work. CMS uses those shares to divide payment when two surgeons split the care under modifiers 54, 55, and 56.
A few services sit outside the package, and each one needs the right modifier or the right biller:
Surgical modifiers on 64721
| Modifier | When it goes on 64721 | Common mistake |
|---|---|---|
| 22 | Documented work well above a typical open release, such as a revision through scar or a conversion with a long dissection | Adding it with no time or difficulty narrative |
| 51 | Another procedure in the same session that NCCI doesn’t bundle, if the payer asks for it | Assuming Medicare needs it; Medicare ranks the procedures on its own |
| 57 | E/M on the day before or day of surgery, when the surgeon decided to operate | Using 25, which fits minor procedures |
| 58 | A planned or staged second procedure inside the global period, including a planned second wrist | Leaving it off the second side |
| 59 or XS | A distinct procedure that an NCCI edit would bundle, backed by documentation | Using it to force the 29848 bundle through; see our modifier 59 rules |
| 78 | Unplanned return to the operating room by the same surgeon for a related complication | Billing the return trip as a new surgery with no modifier |
| 79 | An unrelated procedure during the global period, such as a trigger finger release on the other hand | Using 78 or 58 instead |
| 80, 82, AS | Assistant at surgery | Billing Medicare, which won’t pay an assistant on 64721 (indicator 1) |
| 47 | Anesthesia by the surgeon | Billing it at all; Medicare doesn’t pay it, and the release includes local anesthesia |
CPT 64721 pays $482.64 in a physician’s office and $423.19 in a facility, national amounts under the 2026 Medicare Physician Fee Schedule at the $33.4009 conversion factor. ASC and hospital cases add a separate facility payment: $948.66 for an ASC and $1,995.02 for a hospital outpatient department, both 2026 national rates.
Your actual 64721 CPT code reimbursement moves with your MAC locality and your payer contracts. National numbers start with these relative value units:
2026 RVUs and national payment for 64721
| Component | Non-facility | Facility |
|---|---|---|
| Work RVU | 4.85 | 4.85 |
| Practice expense RVU | 8.61 | 6.83 |
| Malpractice RVU | 0.99 | 0.99 |
| Total RVUs | 14.45 | 12.67 |
| Payment at $33.4009 | $482.64 | $423.19 |
| Payment at $33.5675 (qualifying APM participants) | $485.05 | $425.30 |
Multiply total RVUs by the conversion factor to get the national payment. Your MAC then applies the geographic practice cost index (GPCI) for your locality, which moves the number up or down.
What Medicare pays for 64721 by setting, 2026
| Setting | Place of service | Surgeon | Facility | Total | Patient pays |
|---|---|---|---|---|---|
| Office | 11 | $482.64 | None | $482.64 | 20% coinsurance after the Part B deductible |
| ASC | 24 | $423 | $948 | $1,371 | $273 |
| Hospital outpatient | 22 or 19 | $423 | $1,995 | $2,418 | $483 |
Source: Office row from the CMS fee schedule; ASC and hospital rows from the Medicare Procedure Price Lookup, rounded 2026 national averages.
The surgeon earns $59.45 more in the office because the practice carries the overhead there. On-campus hospital cases use place of service 22 on the surgeon’s claim, and our POS 22 billing rules cover the edge cases.
The hospital bills its own side of the case on the UB-04. That facility claim follows outpatient prospective payment rules, the work our hospital revenue cycle management team handles.
Payment for two sides or two procedures follows set percentages:
CMS set two conversion factors for the first time: $33.4009 (up 3.26%) and $33.5675 for qualifying alternative payment model (APM) participants (up 3.77%), per the CMS 2026 fee schedule fact sheet. The final rule also cut work RVUs by 2.5% for services not billed by time.
64721 national values, 2025 vs 2026
| 64721, national | 2025 | 2026 | Change |
|---|---|---|---|
| Work RVU | 4.97 | 4.85 | 2.5% efficiency adjustment |
| Practice expense RVU, facility | 7.53 | 6.83 | Lower |
| Practice expense RVU, non-facility | 7.76 | 8.61 | Higher |
| Conversion factor | $32.3465 | $33.4009 | Up 3.26% |
| Office payment | $443.79 | $482.64 | Up 8.8% |
| Facility payment | $436.35 | $423.19 | Down 3.0% |
Facility-based surgeons took the hit. The same adjustment cut the work RVUs for 29848 (6.39 to 6.23), 64718 (7.26 to 7.08), and 64719 (4.97 to 4.85), and the 29848 facility payment fell 5.3%, from $512.69 to $485.65. CMS also added 64728 with its own prices.
Yes. Part B covers carpal tunnel release when the record supports medical necessity, and your MAC reviews the documentation if it asks for records. Medicare Advantage plans set their own copays, so an Advantage patient’s share can differ from the averages below.
Patients ask about the cost of carpal tunnel surgery before anything else, and their share depends more on the setting than on the carpal tunnel release surgery CPT code. Using Medicare.gov’s national averages, a patient pays about $273 in an ASC and $483 in a hospital outpatient department. In the office, it’s 20% of the allowed amount after the deductible.
Divide your contracted allowed amount by the 2026 Medicare amount for the same setting. That percentage is the number to bring into contract talks. Pull the allowed amounts from your own 835 remittances, and check insurers’ Transparency in Coverage files, where plans publish their negotiated rates.
If a 64721-50 line keeps paying at 100% instead of 150%, our payment posting services flag it against your payer contract the day the electronic remittance advice (ERA) posts, so you catch the short payment before it ages.
CPT 64721 can share a claim with another procedure when NCCI doesn’t bundle the pair, or when the second procedure sits on a separate site with its own documentation and the right modifier. Medicare pays the higher-valued code at 100% and the next at 50%, and pairs with modifier indicator 0 never pay.
Same-session pairs where both codes can pay (NCCI practitioner PTP edits v323r0, effective October 1, 2026)
| Second code | What it is (paraphrased) | NCCI edit with 64721 | How both pay | 2026 national physician rate, facility |
|---|---|---|---|---|
| 64718 | Ulnar nerve release or transposition at the elbow | None | List 64718 first; 64721 drops to 50% | $575.16 |
| 26055 | Trigger finger release | None | Finger modifier (FA and F1 to F9); list 64721 first | $287.58 |
| +64727 | Internal neurolysis with an operating microscope (add-on) | None | Paid in full with no multiple procedure cut; the op note must describe the microscope and the internal neurolysis | $144.96 |
| 29848 | Endoscopic carpal tunnel release | 64721 column 1, 29848 column 2, indicator 1 | Other wrist only: 64721-RT with 29848-LT | $485.65 |
| 20526 | Carpal tunnel injection | 64721 column 1, 20526 column 2, indicator 1 | Other wrist only: 64721-RT with 20526-LT | $49.43 (office $88.18) |
| 64719 | Ulnar nerve release at the wrist | 64721 column 1, 64719 column 2, indicator 1 | Separate Guyon’s canal exposure for documented ulnar nerve compression; 64719-XS | $387.78 |
ASCs rank the same way, since ASC Addendum AA flags 64721, 29848, 26055, 64718, and 64719 for the multiple procedure discount. A hospital outpatient claim gets one comprehensive APC payment for the whole encounter.
Pairs that don’t pay alongside 64721
| Code | What it is (paraphrased) | NCCI edit | Rule |
|---|---|---|---|
| 25115 | Radical excision of flexor tendon sheath synovium or bursa, wrist or forearm | 25115 column 1, 64721 column 2, indicator 1 | Bill 25115 alone when the release is part of the same exposure |
| 25020 | Decompression fasciotomy, forearm or wrist | 25020 column 1, 64721 column 2, indicator 1 | Bill 25020 alone for the same exposure |
| 25607 | Open treatment with internal fixation of an extra-articular distal radius fracture | 25607 column 1, 64721 column 2, indicator 1 (misuse rationale) | A release through the fracture approach isn’t separate |
| 25111 | Wrist ganglion excision | 64721 column 1, 25111 column 2, indicator 1 | Only a separate site with its own incision |
| 20550 | Tendon sheath injection | 64721 column 1, 20550 column 2, indicator 1 (misuse rationale) | Never for the release’s own local anesthetic |
| 64450 | Peripheral nerve block | 64721 column 1, 64450 column 2, indicator 1 | Not when the surgeon gives it as the anesthetic |
| 69990 and 01810 | Operating microscope; anesthesia for the forearm, wrist, and hand | Indicator 0 for both | Never on the surgeon’s claim |
Yes. The CPT for cubital tunnel release is 64718, and the October 1, 2026 PTP file has no edit between 64718 and 64721 in either direction. List CPT 64718 first: at $575.16 (2026, national, same in office and facility), it outranks the $423.19 facility rate for 64721, so 64718 pays 100% and 64721 pays 50%, about $211.60.
Each code has an MUE of one unit per day (MAI 2) and takes its own RT or LT. Code the ulnar nerve with G56.21 or G56.22 and the median nerve with G56.01 or G56.02, matched to the side of each incision.
Only with proof of a separate problem. The ulnar nerve decompression CPT code at the wrist is 64719, and the October 1, 2026 PTP file makes it column 2 of 64721 (modifier indicator 1, rationale “Standards of medical/surgical practice”). A routine look at the ulnar nerve through the carpal tunnel incision is part of 64721.
Bill 64719-XS when the op note shows a separate Guyon’s canal exposure for documented ulnar nerve compression, coded G56.21 or G56.22. As the Guyon’s canal release CPT code, 64719 ($387.78) ranks second behind 64721 and pays 50%, about $193.89.
Not through the same exposure. CPT 25115 is a radical excision of the bursa or synovium of the flexor tendon sheaths at the wrist or forearm, used for conditions such as rheumatoid tenosynovitis. The October 1, 2026 PTP file makes 25115 column 1 and 64721 column 2 (modifier indicator 1).
That direction matters: the release during the tenosynovectomy is part of 25115, so you bill 25115 alone at $703.42 (2026, national). Some answers online reverse that relationship. Codes 25020 and 25607 work the same way.
20526 is the CPT code for carpal tunnel injection. It pays $88.18 in the office and $49.43 in a facility (2026, national), carries a 0-day global, and allows one unit per day (MAI 2).
Same wrist, same day as 64721: NCCI bundles the injection under a misuse edit, so don’t bill it. For the other wrist, 64721-RT with 20526-LT pays both. An injection weeks before surgery sits outside the 90-day package, which starts the day before surgery.
NCCI Chapter I applies PTP edits to one provider’s services for a patient on one date, so a different physician’s injection doesn’t hit the surgeon’s edit. In groups where hand surgery and pain management share billing, a team that sees both specialties’ denial patterns catches these pairs, the model behind our multi-specialty clinic billing.
Surgeons perform carpal tunnel release under CPT 64721 with local anesthesia such as wide awake local anesthesia no tourniquet (WALANT), a regional block, sedation, or general anesthesia. For billing, the person matters more than the type: the surgeon’s own anesthesia is part of 64721, and a separate anesthesia provider bills 01810, the anesthesia code for forearm, wrist, and hand procedures.
Match the claim to whoever gave the anesthetic:
Both rules come from NCCI Chapter II. For the surgeon, it says, “Medicare does not allow separate payment for anesthesia services performed by the physician who also furnishes the medical or surgical service.”
Section B.4 handles the block: peripheral nerve block codes “shall not be reported separately on the same date of service as a surgical procedure if used as the primary anesthetic technique.” That rule reaches blocks an anesthesiologist places as the main anesthetic, too.
The anesthesia provider’s payment runs on units. 01810 carries three base units, and CMS kept anesthesia base units unchanged for CY 2026. Time units equal anesthesia minutes divided by 15, so a 30-minute case adds two time units.
At the 2026 national anesthesia conversion factor of $20.4975 ($20.5998 for qualifying APM participants), that 30-minute case works out to five units, or $102.49, before your locality adjustment. Our anesthesia CPT code rules cover the modifiers and time reporting in more depth.
CPT 64721 claims need a carpal tunnel syndrome diagnosis coded to the operated side: G56.01 for the right wrist, G56.02 for the left, and G56.03 when both wrists have it. Payers also expect proof that testing confirmed the diagnosis and that conservative care failed, or a documented reason the surgeon skipped it.
ICD-10 code for carpal tunnel release claims
| Code | Meaning | Use with |
|---|---|---|
| G56.00 | CTS, unspecified upper limb | Avoid: the op note names a side |
| G56.01 | CTS, right upper limb | 64721-RT |
| G56.02 | CTS, left upper limb | 64721-LT |
| G56.03 | CTS, bilateral upper limbs | 64721-50, or the first side of a staged pair (Guidelines Section I.B.13) |
| G56.21, G56.22 | Lesion of ulnar nerve, right or left | 64719 or 64718 in the same session |
| M65.331 (M65.3 family) | Trigger finger, right middle finger | 26055-F7 |
Each payer approves surgery when the chart meets its written criteria, and those criteria differ from one payer to the next. Two published policies show how far apart they sit:
Carpal tunnel release criteria at two payers
| Criterion | Anthem CG-SURG-112 (last reviewed November 6, 2025) | Premera 7.01.595 (effective July 1, 2026) |
|---|---|---|
| Diagnosis | Consistent history, physical exam and/or confirmatory electrodiagnostic testing | Electrodiagnostic testing confirms CTS, or a CTS-6 score greater than 12 |
| Conservative care | Symptoms refractory to 6 weeks of hand or wrist immobilization, or to local steroid injections | No response to at least 6 weeks of night splinting or a corticosteroid injection |
| When you can skip conservative care | Progressive symptoms with denervation or axonal loss confirmed by electrodiagnostic testing | Thenar wasting, impaired two-point discrimination on the thumb side, or other severe symptoms |
| Covered | 29848, 64721 | Open or endoscopic release (29848, 64721) |
| Not covered | 64728, 25999, and 64999; thread release; ultrasound-guided needle release; internal neurolysis and other adjuncts | Thread release, ultrasound-guided needle release, and balloon dilation release, all investigational |
The Anthem column comes from Anthem CG-SURG-112, last reviewed November 6, 2025. Premera’s criteria come from Premera policy 7.01.595, effective July 1, 2026.
Write the criteria into the chart in the payer’s own words. Reviewers look for the electrodiagnostic test date, the splint start date, the injection date, and any thenar wasting. A note that says “failed conservative treatment” with no dates gives a reviewer nothing to approve.
Not in Original Medicare. The hospital outpatient prior authorization list in 42 CFR 419.83 covers blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, cervical fusion with disc removal, implanted spinal neurostimulators, and facet joint interventions. Carpal tunnel release isn’t on it, but your MAC can still review medical necessity from the record after the claim.
Medicare Advantage and commercial plans set their own authorization rules, so check at scheduling; our write-up on orthopedic prior authorization challenges covers the common traps. If the planned code changes, such as 29848 converting to 64721 or a switch to 64728, update the authorization before the claim goes out.
Workers’ compensation cases follow the carrier’s authorization and the state fee schedule instead of Medicare rules. The workup sits outside the surgical package too: nerve studies and imaging bill on their own dates, and hand films follow our CPT 73130 hand X-ray guide.
If authorizations for hand surgery keep landing after the surgery date, or your schedulers book a 64728 case before anyone reads the plan’s policy, our prior authorization support checks benefits and the plan’s authorization requirements before the patient reaches the exam room.
A CPT 64721 claim holds up in a records request when the chart shows five things: how testing confirmed the diagnosis, the conservative care that failed, the authorization, an operative report naming the side and the open approach, and who gave anesthesia. Collect them before the claim goes out; after a denial, you’re rebuilding the file under an appeal deadline.
Before surgery, the chart needs:
In the operative report, look for:
After surgery, recovery visits and complications need their own records:
A chart built from these records is what clean claim standards look like for a surgical case. The issue is timing: coders can only code what the op note says, so the review that catches a missing side or approach belongs in the middle of the revenue cycle.
That coding review sits between charge capture and submission in our end-to-end RCM services, which is where a missing side modifier costs the least to fix.
CPT code 64721 examples below show how one open release turns into different claim lines depending on the side, the setting, the timing, and what else happened in the operating room. Each row lists the codes, modifiers, and ICD-10-CM codes as they’d appear on the claim, with the rule behind them.
64721 coding examples, 2026
| Scenario | Physician claim | ASC claim | Why |
|---|---|---|---|
| Right open release after eight weeks of failed night splinting, with nerve studies confirming CTS | 64721-RT, G56.01 | 64721-RT | The side matches in the header, narrative, modifier, and diagnosis |
| Both wrists, same session, Medicare patient | 64721-50, one unit, G56.03; pays 150%, or $634.78 in a facility | 64721-RT and 64721-LT, one unit each: $948.66 + $474.33 | NCCI Chapter I, Section V for the surgeon; Claims Processing Manual, Chapter 14 for the ASC |
| Left endoscopic release converted to open | 64721-LT, G56.02; no 29848 | 64721-LT | NCCI Chapter VIII, Section C.13; add 22 only with documented extra work |
| Planned staged release: right side March 3, 2026, left side April 14, 2026 | First claim 64721-RT, G56.03; second claim 64721-58-LT, G56.02 | 64721-RT, then 64721-LT | The first op note documents the plan, and a new 90-day global starts with the second side |
| Right release plus right middle trigger finger | 64721-RT (G56.01); 26055-F7 (M65.331), with 51 if the payer asks | Both lines, second at 50% | Medicare pays 26055 at 50%, or $143.79 in a facility |
| Right release plus Guyon’s canal release through a separate incision | 64721-RT (G56.01); 64719-XS-RT (G56.21) | Both lines, second at 50% | 64719 pays 50%, about $193.89, with documented ulnar nerve compression |
| New patient seen the day before surgery, when the surgeon decides to operate | Day 1: 99203-57 (G56.01); day 2: 64721-RT | 64721-RT | Modifier 57 marks the decision-for-surgery visit; see CPT 99203 new patient visits |
| Distal radius fracture fixation with the release through the same approach | 25607-RT alone, with the fracture diagnosis from the S52.5 family coded to all seven characters | 25607-RT | 64721 is column 2 of 25607 in the PTP edits |
Coders miss two of these rows more than the rest. The bilateral row changes format between the surgeon’s claim and the ASC’s claim, and First Coast, a Medicare contractor, says “ASCs would not use modifier -50.” The staged row changes the diagnosis between surgeries even though both wrists had CTS from the start.
Payment modifiers go before RT or LT on the claim line, so 64721-58-LT reads the way payers expect, while 64721-LT-58 can trip a payer edit. Keep that order on staged and distinct-procedure lines.
CPT 64721 denials come back with a small set of claim adjustment reason codes (CARCs), and each one points to a specific fix: a side or modifier error, a bundled second procedure, units over the daily limit, a missing authorization, or a medical necessity gap. Read the code on the remittance before you rework the claim.
The table uses definitions from the X12 claim adjustment reason codes list, the standard behind the codes on your 835 remittance.
64721 denial codes and fixes
| CARC | What it means (X12) | Typical 64721 cause | Fix |
|---|---|---|---|
| CO-4 | Procedure code inconsistent with the modifier | RT or LT missing; modifier 50 on an ASC claim; 50 plus RT and LT on one line | Correct the modifier and resubmit |
| CO-11 | Diagnosis inconsistent with the procedure | G56.02 on a 64721-RT line, or G56.00 on the claim | Code the operated side |
| CO-97 | Included in another service already adjudicated | 29848 or 20526 on the same wrist; a routine post-op visit billed inside the 90 days | Don’t rebill; use 24 or 79 for something unrelated |
| CO-236 | Not compatible with another procedure on the same day under NCCI | 64719 or 25111 billed without XS; 69990 or 01810 (indicator 0) | Add XS with separate-site documentation, and remove indicator 0 codes |
| CO-151 | Information doesn’t support this many services (Noridian uses it for MUE denials) | Two units on one line, or RT and LT lines on a physician claim | Rebill as 64721-50, one unit. CMS MLN Matters SE1422 says, “Do not use modifiers RT and LT when modifier -50 applies.” |
| CO-197 | Precertification or authorization absent | Plan authorization missing, or on file for 29848 when the case converted to 64721 | Request a retro authorization under the plan’s rules; see eligibility vs prior authorization |
| CO-50 | Not deemed a medical necessity | Criteria missing from the chart, or 64728 under Anthem or Premera | Appeal with the nerve study results or CTS-6 score and the conservative care dates |
Start by sorting the denial. Coding errors in the side, the modifier, or the units need a corrected claim, and Medicare handles minor clerical errors as reopenings through your MAC. An MUE denial with MAI 2 belongs in that group too, because NCCI Chapter I, Section V bars an override on reopening or redetermination.
Bundling and medical necessity disputes go to a redetermination. CMS gives the appellant “120 days from the date of receipt of the initial claim determination to file a redetermination request,” and in most cases the MAC sends its decision “within 60 days of receipt of the request for redetermination.” Commercial plans follow the appeal window in your contract.
Appeals on 64721 turn on op note language, so the team working them needs the full chart along with the remittance. Our denial management services work each appeal from the chart, recovering the current denial while tracing its cause back to the front end.
Denied 64721 claims that sit past 90 days while someone waits on records need an owner, because filing and appeal windows keep running. That backlog is where aged claim recovery work starts.
If your 64721 denials keep landing in the same two or three reason codes, you’re looking at a pattern. Our team sorts denials within 24 hours and fixes the rule behind them through orthopedic denial management, so the next bilateral or staged case goes out clean.
The CPT code for carpal tunnel release surgery depends on the approach. Report 64721 for an open release, 29848 for an endoscopic release, and 64728 for a percutaneous release with balloon dilation, a code that took effect January 1, 2026.
Append RT or LT, and report 64721 alone when an endoscopic case converts to open. Code from the op note, since the approach can change in the operating room.
No single code covers wrist surgery. Most open wrist procedures sit in the 25000 to 25999 range, and wrist arthroscopy runs from 29840 to 29848.
Carpal tunnel release lives in the Nervous System section as 64721, because the surgeon is treating the median nerve. A median nerve release belongs under 64721 even when the schedule calls it wrist surgery.
Both codes release the transverse carpal ligament. 64721 does it through an open incision, and 29848 does it through a wrist endoscope. Each carries a 90-day global period and takes RT or LT.
29848 has the higher 2026 work RVU, 6.23 against 4.85, and a national facility rate of $485.65 against $423.19 for 64721. You can’t bill both on the same wrist.
Yes. On a Medicare physician claim, bill 64721-50 with one unit, and Medicare pays 150%, which comes to $634.78 in a facility in 2026. An ASC bills 64721-RT and 64721-LT as two lines, with the second at 50%.
Some commercial plans want RT and LT lines from the surgeon too, so check the payer’s bilateral policy. A second wrist done later inside the 90 days takes modifier 58 if planned or 79 if not.
Medicare’s 2026 national physician rate for 64721 is $482.64 in the office and $423.19 in a facility, at a $33.4009 conversion factor. Qualifying APM participants get $485.05 and $425.30 at $33.5675.
Facilities collect their own payment on top of that: $948.66 for an ASC and $1,995.02 for a hospital outpatient department under the July 2026 CMS addenda. Your locality and your contracts change the final figure.
With Original Medicare, a patient’s national average share is about $273 in an ASC and $483 in a hospital outpatient department, based on Medicare.gov’s 2026 figures before any supplemental coverage.
Office cases carry 20% coinsurance on the allowed amount after the Part B deductible. Commercial patients pay their plan’s deductible and coinsurance on the contracted rate, so the plan’s cost estimator gives the most reliable number.
Original Medicare doesn’t require it. Carpal tunnel release isn’t on the hospital outpatient prior authorization list in 42 CFR 419.83. Medicare Advantage and commercial plans set their own rules, so check each plan at scheduling.
If the planned code changes, such as 29848 converting to 64721, update the authorization before the claim goes out. Anthem calls 64728 not medically necessary and Premera calls it investigational, so expect pushback on that code.
The 64718 CPT code description covers ulnar nerve release at the elbow, and its two neighbors cover the wrist and the microscope add-on. In plain language, with 2026 national facility rates:
64718 and 64719 carry 90-day global periods like 64721. As an add-on, +64727 has no global period of its own and follows the primary code.
The 64722 CPT code description, paraphrased, is decompression of an unspecified nerve, with the nerve named in the record. It can’t stand in for 64721, because 64721 is the specific code for the median nerve at the carpal tunnel.
NCCI also lists 64722 as a column 2 code of 64721, with modifier indicator 1, so an extra 64722 line needs a separate site and a modifier to pay.
CPT 64708 is an open neuroplasty of a major arm or leg nerve that no other code names. For a nerve of the hand or foot, CPT 64704 applies instead.
Neither one replaces 64721 at the carpal tunnel, and NCCI lists 64721 as a column 2 code under both of them, with modifier indicator 1. Code 64721 whenever the op note describes the median nerve at the carpal tunnel.
A clean CPT 64721 claim comes from five checks before submission. You pick the code from the approach, and the modifier and diagnosis from the operated side. Then you match the claim format to the setting, clear any second procedure through NCCI, and make sure the chart proves medical necessity in the payer’s own terms.
If you’d rather hand that workflow to a team that bills orthopedic surgery claims, look at our hand surgery billing support. For a smaller first step, send us your last 90 days of hand surgery claims for a free revenue cycle audit, and we’ll show you where 64721 payments are leaking.
CPT 49650 is the code for the laparoscopic repair of an initial inguinal hernia on one side. It includes mesh when the surgeon places it. In 2026, the surgeon’s national Medicare rate is $424.19, and the code carries a 90-day global period.
Billing teams tend to trip on four calls with the 49650 CPT code. Coders mix up initial and recurrent repairs, and billers send bilateral cases in a line format the payer rejects. Staff also add a robotic code Medicare won’t pay. Others copy age language from another code.
These calls come up in ASCs, hospital outpatient departments, and surgical practices alike. The correct inguinal hernia repair CPT code comes first below. Payment and modifier rules come next. At ClaimMax RCM, these are the checks our coders run on hernia claims.
Coders check these 2026 facts first on a 49650 case.
| Item | 49650 detail |
|---|---|
| Descriptor | Laparoscopy, surgical; repair initial inguinal hernia |
| Approach | Laparoscopic, including TEP, TAPP, and robotic-assisted repair |
| Laterality | Unilateral; modifier 50 for a bilateral repair |
| Mesh | Included when the surgeon places it |
| Global period | 090 (major surgery) |
| 2026 work RVU | 6.20 |
| 2026 national surgeon rate | $424.19 non-APM, $426.31 APM (facility setting only) |
| Recurrent hernia | 49651 |
| Open initial repair | 49505 or 49507 (age 5 or older) |
| Robotic code | None in CPT; HCPCS S2900 has status I for Medicare |
49650 at a glance, 2026 Medicare data. Sources: AMA CPT descriptor and the CMS RVU26D relative value file.
CPT code 49650 covers one side of a laparoscopic inguinal repair when the hernia is initial, meaning no surgeon has repaired that site before. TEP, TAPP, and robotic approaches all fall under it at the same payment. Recurrent and open repairs use other codes.
The AMA descriptor for 49650 reads, “Laparoscopy, surgical; repair initial inguinal hernia.” That’s the whole descriptor. CMS shortens it to “Lap ing hernia repair init,” and that’s the text you’ll see on a Medicare remit.
Open inguinal codes split by the patient’s age and by whether the hernia is reducible or incarcerated. Laparoscopic coding has no such split. The CPT line reads 49650 for a 30-year-old with a reducible hernia and for a 70-year-old with an incarcerated one. Only the diagnosis changes.
Common mistake: some code lookup tools attach an age limit and a reducible requirement to 49650. Both belong to 49505, the open repair code.
The surgeon works through small ports with a camera, reduces the hernia contents, and places mesh in the preperitoneal space. In a TAPP (transabdominal preperitoneal) repair, the surgeon enters the peritoneal cavity first. With a TEP (totally extraperitoneal) repair, the surgeon stays outside it. A robot can assist with either.
Each version shares one CPT code for laparoscopic inguinal hernia repair, so the claim doesn’t show which one the surgeon used. The op note has to. It should say “laparoscopic” or “robotic,” because a note that only reads “hernia repair with mesh” won’t support 49650.
Some dictation templates still say “laparoscopic herniorrhaphy.” That describes the same procedure. There’s no separate herniorrhaphy CPT code, so an initial inguinal case still goes on the claim as 49650.
Yes. Mesh placement is part of CPT 49650, so there’s no separate CPT code for inguinal hernia repair with mesh. The old add-on code +49568 never applied to inguinal repairs, and the AMA deleted it on January 1, 2023.
NCCI policy bars mesh codes with a hernia repair unless a CPT instruction allows them. No instruction allows one with 49650, and the NCCI section below gives the exact rule.
Hospitals may report the mesh on the facility claim, such as with HCPCS C1781, for cost tracking. Medicare packages it into the facility payment. Tacks and glue used to fix the mesh don’t earn separate payment on either claim.
Coders pick the CPT code for inguinal hernia repair from four facts in the op note. No single hernia repair CPT code covers every case, so check the four facts in this order:
CPT 49650 is the right code when the repair is laparoscopic, the hernia is inguinal, and that site has no prior repair. If any one differs, the code changes.
CPT 49651 is the laparoscopic code for a hernia that comes back at a site a surgeon repaired before. Medicare pays more for it. In 2026, 49651 has a work RVU of 8.17 and a national rate of $550.11, about $126 above 49650.
Check that the op note documents the recurrence. A prior repair on the left side doesn’t make a new right-side hernia recurrent. Match the diagnosis as well: K40 codes with a fifth character of 1 mean recurrent, and the diagnosis section below lists all 12.
Don’t use 49656 for a recurrent inguinal repair. It was a laparoscopic incisional hernia code, and the AMA deleted it on January 1, 2023.
CPT code 49505 is the open repair of an initial, reducible inguinal hernia in a patient age 5 or older. An incarcerated or strangulated hernia takes 49507. Open pediatric repairs under age 5 use 49491 through 49501.
Recurrent open repairs go to 49520, or 49521 when the hernia is incarcerated or strangulated. A sliding hernia takes 49525. Take the open inguinal hernia repair CPT code from the op note’s findings, since the booked procedure and the actual findings can differ.
If the surgeon converts a laparoscopic case to open, report only the open code that matches the documented findings. Leave 49650 off the claim. The note should give the reason for the conversion, such as dense adhesions or bowel that won’t reduce through the ports.
Yes. A robotic-assisted repair of an initial inguinal hernia goes on the claim as 49650, or 49651 if recurrent. There’s no separate robotic inguinal hernia repair CPT code and no robotic modifier. The lap inguinal hernia repair CPT code covers the surgeon’s work with or without the robot.
HCPCS code S2900 describes robotic assistance. CMS gives it status I in the 2026 relative value file, so Medicare won’t pay it. Bill it only when a commercial contract names it. Our HCPCS vs. CPT code guide explains how Level II codes work next to CPT codes.
Inpatient facility claims use ICD-10-PCS. For a repair with mesh, hospitals report 0YU54JZ for the right side, 0YU64JZ for the left, or 0YUA4JZ for both. They add 8E0W4CZ for robotic assistance. None of these codes appear on the surgeon’s claim.
The 49650 CPT code still applies when the surgeon repairs an incarcerated initial hernia through the laparoscope. CPT Assistant corrected a January 2009 answer in July 2014: 49650 doesn’t separate reducible from incarcerated hernias, so 49659 doesn’t apply. Documented extra work may support modifier 22.
Femoral hernias are different. A laparoscopic femoral hernia repair CPT code doesn’t exist, so AAPC guidance from September 2025 points those repairs to unlisted 49659. The 49659 CPT code is carrier priced, so send the op note and a comparison code that helps the payer value it.
If the surgeon repairs an inguinal and a femoral hernia in the same session, ask the payer how it wants the pair reported. Payer policies differ here.
CPT 49652 through 49657 covered laparoscopic ventral, umbilical, and incisional repairs until the AMA deleted them on January 1, 2023. Those repairs now use 49591 through 49618 for any approach, sized by the total defect. Open umbilical codes such as 49585 went too.
The last column shows the op note finding that decides each code.
| Scenario | Code | What decides it |
|---|---|---|
| Initial, laparoscopic or robotic | 49650 | No prior repair at that site |
| Recurrent, laparoscopic or robotic | 49651 | Prior repair documented at that site |
| Initial, open, age 5 or older, reducible | 49505 | Hernia reduces |
| Initial, open, age 5 or older, incarcerated or strangulated | 49507 | Hernia doesn’t reduce |
| Recurrent, open, reducible | 49520 | Prior repair, hernia reduces |
| Recurrent, open, incarcerated or strangulated | 49521 | Prior repair, hernia doesn’t reduce |
| Sliding hernia, open | 49525 | Sliding hernia documented |
| Laparoscopic femoral, or another hernia with no laparoscopic code | 49659 | Unlisted; send the op note |
| Ventral, umbilical, incisional, epigastric, or spigelian | 49591 through 49618 | Any approach; never 49650 |
Inguinal hernia repair code selection, 2026 CPT code set.
If initial-versus-recurrent calls or robotic claims keep getting denied, the fix starts with the op note. Our surgical billing service reviews it on hernia claims before your team submits them.
In 2026, Medicare’s national rate for the surgeon on 49650 is $424.19 in a facility setting. The facility bills its own claim: $3,030 at an ambulatory surgery center and $6,176 at a hospital outpatient department, before local adjustment. Setting doesn’t change the surgeon’s rate.
In 2026, CPT code 49650 has 12.70 RVUs. The CMS 2026 relative value files split that total into three parts. Multiply the total by the conversion factor to get the national rate. Your Medicare contractor then applies three GPCIs, one for each RVU component, for your locality.
| RVU component | 2026 value |
|---|---|
| Work | 6.20 |
| Practice expense, facility | 4.87 |
| Malpractice | 1.63 |
| Total | 12.70 |
2026 facility RVUs for 49650. Source: CMS RVU26D.
At the non-APM conversion factor of $33.4009, the 49650 allowed amount works out to $424.19 before GPCI. Qualifying APM participants get $426.31 at $33.5675. CMS lists the code with status A and a 090 global, so Medicare pays it under the fee schedule as major surgery.
There’s no office rate. CMS marks the non-facility practice expense for 49650 as NA because surgeons don’t perform this repair in an office. Any $424.19 figure labeled non-facility is the facility rate under the wrong name.
CPT 49650 reimbursement fell $3.43 in 2026, even though the conversion factor rose 3.26%. Medicare’s 2025 national rate was $427.62, from 13.22 RVUs at $32.3465.
CMS made two changes. In the CY 2026 Physician Fee Schedule final rule, CMS cut work RVUs for non-time-based services by 2.5%. The 49650 work RVU dropped from 6.36 to 6.20. Facility practice expense fell from 5.27 to 4.87 after CMS gave office settings a larger share of indirect costs.
Other facility-based surgical codes took the same hit. The laparoscopic cholecystectomy CPT codes guide shows the same efficiency adjustment on 47562.
One 49650 case produces three claims: the surgeon’s, the facility’s, and the anesthesia provider’s. The facility claim is the largest. For 2026 national averages by setting, check the Medicare Procedure Price Lookup.
| Setting (2026 national) | Facility fee | Total approved with surgeon’s fee | Medicare pays | Patient pays |
|---|---|---|---|---|
| Ambulatory surgery center (POS 24) | $3,030 | $3,454 | $2,763 | $690 |
| Hospital outpatient department (POS 22) | $6,176 | $6,600 | $5,280 | $1,319 |
Medicare-approved amounts for 49650 by setting, 2026 national averages. Source: Medicare Procedure Price Lookup.
Medicare covers 49650 in both outpatient settings. The surgeon’s place of service follows the facility: POS 24 for an ASC and POS 22 for an on-campus hospital outpatient department. An off-campus department takes POS 19. The POS 22 billing rules guide covers the on-campus hospital case.
Put 49650 next to CPT code 49505, the open initial repair, and the split is clear: Medicare pays the surgeon less and the facility more.
| Code | Surgeon rate (2026 national) | ASC facility fee | HOPD facility fee |
|---|---|---|---|
| 49650, laparoscopic initial | $424.19 | $3,030 | $6,176 |
| 49651, laparoscopic recurrent | $550.11 | $3,030 | $6,176 |
| 49505, open initial | $508.03 | $1,744 | $3,657 |
2026 national Medicare rates. Sources: CMS RVU26D and Medicare Procedure Price Lookup.
The surgeon earns about $84 less for the laparoscopic repair than for the open one. Facility payment is about 1.7 times as much. Both claims have to report the same approach from the same op note, because a payer that compares them can spot a mismatch.
Commercial rates depend on each contract. If your 49650 remits don’t match what you signed, you’ll catch the gap in payment posting. Our surgical revenue cycle management team checks allowed amounts on surgical remits against each contract.
CPT code 49650 usually needs a modifier. Most payers want RT or LT on a one-sided repair, and a repair of both sides takes modifier 50. A second procedure in the same session may need 51, 59, or XS. Team and global period rules add a few more.
No. CPT treats 49650 as a unilateral procedure, and AAPC hernia coding guidance lists the whole inguinal range from 49491 through 49651 as unilateral. If the surgeon repairs both sides in one session, report 49650 once with modifier 50.
Medicare wants a single line: 49650-50, one unit. CMS gives 49650 a bilateral surgery indicator of 1, so Medicare allows 150% of the fee schedule amount, a $636.29 national rate at non-APM. The Medicare Claims Processing Manual, Chapter 12 sets out that 150% rule.
Commercial payers don’t all agree. Some want two separate lines, 49650-RT and 49650-LT, each with its own charge. Others want modifier 50 with two units. Follow the payer’s written policy and keep a copy of it. In each format, the diagnosis is a bilateral K40 code such as K40.20.
A payer that wants two lines will often deny a single-line 49650-50 with CARC 4, the modifier mismatch code. Log each payer’s format in your system. If CARC 4 keeps showing up anyway, a denial management team can trace which payer rule changed.
The left inguinal hernia repair CPT code is 49650 with modifier LT, and a right-side repair takes RT. ICD-10-CM inguinal codes only say unilateral or bilateral, so the side shows up on the claim only through the modifier. Check the modifier on every line.
Laterality matters most when the surgeon repairs the other side later in the 90-day global period. That second claim needs the opposite-side modifier plus a global modifier such as 58 or 79. Without both, payers see a duplicate claim.
CMS assigns multiple procedure indicator 2. Medicare allows 100% for the highest-valued procedure in the session and 50% for each additional one. It applies that reduction itself, while some commercial payers want modifier 51 on the lower-valued line.
With an anterior abdominal repair in the same session, American College of Surgeons coding guidance allows a separate inguinal line with modifier 59, as appropriate. CMS prefers XS (separate structure) when it fits. For the XS-versus-59 decision, see modifier 59 and X modifiers.
You can bill 49592 and 49650 together when the surgeon repairs the two hernias at separate sites. Check the NCCI edit first. Its modifier indicator shows whether 59 or XS can bypass it.
Modifier 22 fits only when the op note shows significant extra work beyond a typical 49650. Dense adhesions from prior pelvic surgery or a large incarcerated hernia can qualify. The surgeon’s note should record the extra time and the reason. Send the op note with the claim.
CMS sets an indicator for each surgical team modifier on 49650 in the 2026 file, and Medicare pays by those indicators:
The table also lists the three modifiers that never apply to 49650.
| Modifier | Use it when | 49650 note |
|---|---|---|
| RT or LT | One side repaired | Shows the side on the claim |
| 50 | Both sides repaired in one session | Medicare allows 150% on one line |
| 51 | Another procedure in the same session | Lower-valued line, if the payer asks |
| 59 or XS | A separate site or structure | Check the NCCI edit first |
| 22 | Documented work well beyond typical | Send the op note |
| 80, 82, or AS | An assistant at surgery | 16%; AS gets 85% of that |
| 62 | Two co-surgeons | 62.5% each, with both notes |
| 54 or 55 | Split surgical and post-op care | 90% and 10% shares |
| 24, 57, 58, 78, or 79 | Services during the global period | See the global period section |
| 52 or 53 | Reduced or discontinued procedure | Payer policy varies |
| 26, TC, or 66 | Never on 49650 | CMS indicators rule them out |
Modifiers for 49650, 2026. Indicators from the CMS RVU26D file.
CPT 49650 is major surgery with a 90-day global period. Medicare counts 92 days: the day before surgery, the day of surgery, and the 90 days after. The surgical fee covers routine follow-up in that window. Don’t bill those visits.
The CMS Global Surgery Booklet spells out what the surgical fee pays for. On a 49650 case, the package includes these services, and none of them gets its own claim line:
Diagnostic tests and visits for unrelated problems stay outside the package, along with distinct procedures that aren’t re-operations. The decision-for-surgery visit is outside it as well. You can bill a return to the operating room for a complication with modifier 78.
Practices with 10 or more practitioners in nine states must report post-op visits with 99024, a $0 tracking code, for the procedures on CMS’s list. The states are Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. CMS proposed pausing that reporting for 2027.
In the same proposal, CMS said its data shows post-op visits in the global period often aren’t happening. It asked for comments on how it should value global surgery.
Five modifiers cover billable work that falls around or inside the 92 days. Each one needs a note that shows why the service is outside the package.
| Modifier | When it applies | 49650 example |
|---|---|---|
| 57 | An E/M visit the day before or day of surgery that produced the decision for surgery | The visit where the surgeon decides to repair the hernia; see our modifier 57 decision for surgery guide |
| 24 | An unrelated E/M visit during the 90 days | An evaluation of a new breast lump, with a note that shows it isn’t about the hernia |
| 58 | A planned or staged procedure | A second-side repair planned at the first surgery; a new global period starts |
| 78 | An unplanned return to the OR for a related complication | A hematoma or mesh infection that needs surgery |
| 79 | An unrelated procedure during the global period | A new hernia on the other side that the surgeon didn’t plan; a new global period starts |
Global period modifiers for 49650. Source: CMS Global Surgery Booklet.
The anterior abdominal codes, 49591 through 49618, carry a 000 global. Inguinal codes carry 090. A follow-up visit for the anterior abdominal repair can be billable. Payer handling varies, and some payers apply the 90-day global to every procedure in the session.
AAPC’s advice in its Ask and Learn column on November 1, 2023, is to document that the visit was for the anterior abdominal repair. List that diagnosis first on the visit’s claim. Appeal with the note if the payer denies it.
NCCI bundles diagnostic laparoscopy and mesh into the repair. It also bundles any hernia repair done at the incision of another open or laparoscopic abdominal procedure. A second hernia repair CPT code is billable when that hernia sits at a separate site and has its own medical reason.
The 2026 NCCI Policy Manual, Chapter 6 sets the rules. Section E.4 says a hernia repair at the site of an incision for an open or laparoscopic abdominal procedure isn’t separately reportable. A repair at a different site, with its own medical need, is.
The mesh rule comes from Section E.7. Under Section F.1, surgical laparoscopy includes diagnostic laparoscopy, so 49320 doesn’t go on a 49650 claim.
Watch the umbilical port. Surgeons often place the camera port at the umbilicus. E.4 bundles an umbilical hernia repaired through that port incision, even if the patient had it before surgery. A separate 49591 needs a repair site other than a port incision.
Surgeons sometimes repair an inguinal hernia during a lap chole (47562). The gallbladder and the groin are separate sites. Report 49650 when the op note supports the hernia’s own medical need, such as symptoms found on the pre-op exam.
Before adding 59 or XS, check the pair in the current CMS NCCI PTP edit tables. The release effective October 1, 2026, is version 323r0. A modifier only helps when that edit’s modifier indicator is 1.
Report a spermatic cord lipoma excision with 55520 alongside the hernia repair. AHA Coding Clinic for HCPCS, which hospital outpatient coders follow, backed that in the fourth quarter of 2023. Reduction alone doesn’t count. The note has to describe an excision.
Coding Clinic revisited the topic in the third quarter of 2024. Check the current guidance before you add 55520, and confirm the surgeon’s payer accepts it on the professional claim. Don’t treat it as automatic.
For a patient age 5 or older, report hydrocelectomy (55040) on its own line with an open inguinal repair. Open pediatric codes 49491 through 49501 include it. AAPC’s guidance on sorting inguinal codes draws the same line for open cases. With 49650, check the NCCI edit for 55040 first.
If the surgeon scopes the groin and finds no hernia to repair, report diagnostic laparoscopy (49320) with the symptom diagnosis, such as groin pain.
Open groin exploration with no repair is harder. No dedicated groin exploration CPT code exists. Some payers accept the repair code with modifier 52, and others want an unlisted code. Ask the payer which CPT code for inguinal exploration it accepts, and get the answer in writing.
A 49650 claim needs a K40 code whose fifth character is 0, meaning “not specified as recurrent.” If the fifth character is 1, the hernia is recurrent and belongs with 49651. The FY 2027 code set takes effect October 1, 2026. Its 12 K40 codes don’t change.
Each row pairs a K40 code with the CPT line it supports.
| Code | CMS description | Pairs with |
|---|---|---|
| K40.90 | Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent | 49650-RT or 49650-LT |
| K40.91 | Unilateral inguinal hernia, without obstruction or gangrene, recurrent | 49651-RT or 49651-LT |
| K40.30 | Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent | 49650, or 49507 if converted to open |
| K40.31 | Unilateral inguinal hernia, with obstruction, without gangrene, recurrent | 49651, or 49521 if converted to open |
| K40.40 | Unilateral inguinal hernia, with gangrene, not specified as recurrent | 49650, or 49507 if converted to open |
| K40.41 | Unilateral inguinal hernia, with gangrene, recurrent | 49651, or 49521 if converted to open |
| K40.20 | Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent | 49650-50 |
| K40.21 | Bilateral inguinal hernia, without obstruction or gangrene, recurrent | 49651-50 |
| K40.00 | Bilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent | 49650-50 |
| K40.01 | Bilateral inguinal hernia, with obstruction, without gangrene, recurrent | 49651-50 |
| K40.10 | Bilateral inguinal hernia, with gangrene, not specified as recurrent | 49650-50 |
| K40.11 | Bilateral inguinal hernia, with gangrene, recurrent | 49651-50 |
FY 2027 ICD-10-CM, effective October 1, 2026. Source: CMS FY 2027 ICD-10-CM code files.
A recurrent hernia on one side and an initial hernia on the other don’t fit a single modifier 50 line. Split the claim. Bill each side on its own line with its own diagnosis, such as 49651-RT with K40.91 and 49650-LT with K40.90.
The right history code depends on the index path. In the FY 2027 index, “history, personal, surgery NEC” leads to Z98.890, and a personal history of digestive disease points to Z87.19.
Use either one only as a secondary code, such as when the surgeon repaired the opposite side years ago. A hernia that came back at the same repaired site gets a recurrent K40 code instead.
In a CMS CERT review of laparoscopic hernia repair claims from July to September 2014, reviewers tied most improper payments to missing documentation. Coding errors came second. They found unsigned op notes, wrong dates of service, and missing signature attestations. One urologist billed 49650-51 for a general surgeon’s repair.
Before you submit a CPT 49650 claim, check that the op note states each of these in plain language:
The review appeared in the CMS compliance newsletter on CERT findings, Volume 6, Issue 2, January 2016. Its examples use retired codes such as 49652. Payers still check a CPT code 49650 claim against the note behind it.
Coders who read the note before billing catch gaps in the first four items, the ones that change the code. We build that pre-bill review into our medical billing for surgical practices. A signed, complete note is also part of what makes a clean claim.
CPT 49650 denials tend to fall into four groups. Coding calls come first: the wrong code for the hernia’s history, the wrong side, or the wrong modifier format. The other three groups are bundled services, missing authorizations, and notes that don’t support the claim.
The table maps each group to X12’s claim adjustment reason codes (CARCs), with the X12 wording shortened.
| CARC | Meaning | Typical 49650 cause | Fix |
|---|---|---|---|
| 4 | Procedure code inconsistent with the modifier | Single-line 50 sent to a payer that wants RT and LT lines | Corrected claim in that payer’s format |
| 11 | Diagnosis inconsistent with the procedure | Recurrent K40 code on 49650, or an initial one on 49651 | Match the code to the history in the note |
| 16 | Missing information or billing error | No laterality, or an unlisted 49659 claim sent without the op note | Add the missing item and resubmit |
| 18 | Exact duplicate claim or service | Second-side repair billed without RT, LT, 58, or 79 | Add the side and the global modifier |
| 50 | Not a medical necessity per the payer | No documented symptoms, or missing required conservative care | Appeal with records, or fix intake |
| 97 | Included in another service | 49320 or a mesh line billed with 49650, or a port-site hernia repair | Write it off, or appeal if the note shows a separate site |
| 197 | Authorization absent | A Medicare Advantage or commercial plan required prior authorization | Ask for a retro authorization or appeal, then fix scheduling |
| 236 | Pair not allowed together under NCCI | A PTP edit between 49650 and a same-day code | Add XS or 59 only if the modifier indicator is 1 |
Common CARC denials on 49650 claims. Source: X12 claim adjustment reason codes.
For CARC 197, the fix belongs at scheduling. Check each plan’s rule before the surgery date; the eligibility and prior authorization guide shows how.
Some underpayments never show up as denials. A bilateral claim paid at 100% instead of 150% posts like a normal payment. You’ll only catch it in a payment posting review that compares each line to the fee schedule. Then recover the difference through accounts receivable follow-up with the payer.
If the same 49650 denial comes back from one payer month after month, the cause sits upstream of the claim. Our denial management services team traces each denial to the payer rule behind it. Then we change the setup that triggers it.
These four claims show how the inguinal hernia repair CPT code, the modifier, and the diagnosis fit together on the CMS-1500. Medicare amounts are 2026 national allowed amounts for non-APM clinicians, before local adjustment. For box-level errors, see our list of CMS-1500 claim form mistakes.
Report 49650-50, one unit, with K40.20 and POS 22 for an on-campus hospital outpatient case. Medicare allows $636.29, or 150% of $424.19. That’s Medicare’s format for the bilateral inguinal hernia repair CPT code.
Use 49651-LT with K40.91 for a commercial PPO patient. CPT has no robotic code to add. Skip S2900 unless the PPO contract lists it, and check what the contract pays for it.
Bill 49650-RT-59 (or XS) and 49591, with diagnoses K40.90 and K42.9. In this case, the umbilical hernia is 2.5 cm and reducible, and the surgeon repaired it at a site other than a port incision.
Medicare applies the 50% cut itself. The allowed amount is $582.01: $424.19 plus 50% of $315.64. Add modifier 51 to 49591 only for payers that ask for it.
Code it as CPT code 49507 with LT and K40.30, and leave 49650 and 49320 off the claim. Medicare’s 2026 national rate is $568.15. The op note should explain why the surgeon converted.
The AMA’s CPT 2027 announcement lists no change to the CPT code for laparoscopic inguinal hernia repair, so the code stays 49650. CMS proposed two payment changes: a lower 2027 conversion factor and a 50% payment for some same-day E/M visits billed with global procedures.
The AMA released CPT 2027 on September 9, 2026. Its 453 changes take effect January 1, 2027, and include 299 new codes, 74 revisions, and 80 deletions. Hernia coding gets nine new codes, all for diaphragmatic hernia repair. Recheck 49650 when the codebook ships.
In the CY 2027 fee schedule proposed rule, released July 14, 2026, CMS proposed a non-APM conversion factor of $32.84, down from $33.40. The APM factor would drop from $33.57 to $33.17. Congress passed a one-year 2.5% increase for 2026. That bump ends in 2027.
If the 2026 RVUs held at 12.70, the proposed $32.84 factor would put 49650 at a $417.07 national rate. The final 2027 RVUs can change. Treat the figure as math on a proposal.
CMS also proposed a same-day cut. It would apply to office and outpatient E/M visits on the same day as a 0-, 10-, or 90-day global procedure. Medicare would pay the lower-valued service at 50%.
A decision-for-surgery office visit billed with modifier 57 on the day of a 49650 case fits that description. Check the final rule for how CMS treats that visit. CMS usually publishes it around November 1.
The main difference is the approach. CPT code 49505 is an open code for initial hernias. It adds two limits: the hernia must reduce, and the patient must be 5 or older. Code 49650 covers a laparoscopic or robotic initial repair at any age, reducible or not.
In 2026, the surgeon’s national Medicare rate is $508.03 for 49505 and $424.19 for 49650. Medicare pays the facility more for the laparoscopic case in both settings. Both codes carry a 90-day global period.
It’s usually outpatient. Medicare covers the facility side of a 49650 case in an ambulatory surgery center or a hospital outpatient department. Patients go home the same day in most cases, after a few hours in recovery.
An inpatient admission needs documented medical necessity, and Medicare expects an inpatient stay to span two midnights. If the hospital admits the patient, its claim groups to the inguinal and femoral hernia MS-DRGs, 350 through 352. The surgeon still bills 49650.
Yes, when the surgeon repairs the two hernias separately, at separate sites. The American College of Surgeons lets you report the inguinal repair on its own line with modifier 59. CMS would rather see XS when it fits.
Check the pair’s NCCI edit before you submit. If the surgeon repaired the umbilical hernia through a laparoscopic port incision, NCCI bundles it. Ask the surgeon to document each hernia’s size and the reason for its repair.
The AMA descriptor reads, “Laparoscopy, surgical; repair recurrent inguinal hernia.” Use CPT 49651 when the patient had a prior repair at the same site. In 2026, it has a work RVU of 8.17. Its national surgeon rate is $550.11.
Robotic recurrent repairs use the same code. Pair it with a K40 code whose fifth character is 1, and confirm the op note names the prior repair. A prior repair on the other side doesn’t count.
Original Medicare doesn’t. Hernia repair isn’t on CMS’s hospital outpatient prior authorization list, so a 49650 case can go ahead without one. Medicare Advantage and commercial plans often require it for elective hernia surgery, and a missing authorization comes back as CARC 197.
Run eligibility and authorization checks when the office schedules the case. Enter the authorization number in Box 23 of the CMS-1500, because payers compare it with the date of service and the approved code.
The anesthesia provider bills general anesthesia on a separate claim. Its code comes from the lower abdomen range, 00800 through 00882, chosen through the ASA crosswalk for the surgical code. The surgeon’s claim has no anesthesia line.
Payment uses base units plus time units, multiplied by the anesthesia conversion factor. Anesthesia claims use their own modifiers. AA means the anesthesiologist performed the case, and QK means medical direction. For the crosswalk and the 2026 math, see the anesthesia CPT code guide.
No. The AMA deleted 49585 on January 1, 2023, along with the other open umbilical and ventral hernia codes. Umbilical repairs now use 49591 through 49596 for an initial hernia or 49613 through 49618 for a recurrent one, by any approach.
Coders pick the exact code by the total defect size and whether the hernia reduces. One code covers every defect in the session. These codes carry a 000 global period, while inguinal repair codes carry a 090 global.
Yes. CPT 49650 is active in 2026. CMS lists it with status A in the 2026 relative value file, and the 49650 CPT code description hasn’t changed. The 2026 national surgeon rate is $424.19.
The K40 diagnosis codes don’t change either. FY 2027 ICD-10-CM takes effect October 1, 2026, with all 12 K40 codes intact and none added. For 2027, the AMA’s CPT announcement lists no change to 49650, though CMS has proposed a lower conversion factor.
Before a CPT code 49650 claim goes out, confirm five points on the claim itself:
If your surgical claims keep stalling on these points, our surgical coding and billing team can review a sample. You can request a claim review through our contact page.
CPT code 99349 is the evaluation and management (E/M) code for a home or residence visit with an established patient. The visit needs moderate medical decision making (MDM) or at least 40 minutes of total time on the date of the encounter. Either one qualifies.
Two things changed for this code heading into 2026. Medicare started paying the G2211 add-on with home and residence visit codes on January 1, 2026. Noridian’s Jurisdiction F medical review team published Targeted Probe and Educate results on 99349 for claims from October 1 to December 31, 2025.
Checked against CMS and AMA sources on September 28, 2026
| Fact | 2026 answer |
|---|---|
| Code family | Home or residence services, established patient (99347 to 99350) |
| Level selection | Moderate medical decision making, or 40 minutes or more of total time on the date of the encounter |
| Time ceiling | None in the descriptor; 60 minutes meets the 99350 threshold |
| Medicare place of service codes | 12, 13, 14, 33, and 55 |
| Status | Active for 2026 dates of service; the AMA revised it in 2023 |
| Global period | XXX, so global surgery rules don’t apply |
| 2026 national Medicare payment | $132.27 (non-QP) or $132.93 (QP), from 3.96 RVUs, before locality adjustment |
| G2211 add-on | Payable with 99349 for Medicare since January 1, 2026 |
| Prolonged service add-on | None at this level; prolonged codes attach to 99350 |
| Homebound requirement | None |
| Medicare telehealth | Listed on the CY 2026 Medicare telehealth services list |
99349 is the established patient CPT code for a moderate-complexity home or residence E/M visit. It sits one level below 99350, the top code in the established patient home series. Picture a patient whose heart failure is getting worse. The provider changes the medication during the home visit.
The CPT code 99349 description comes from the AMA’s 2023 E/M revision, and claims for 2026 dates of service use the same wording. It reads in full:
Home or residence visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.
Source: AMA’s 2023 E/M guidelines. The AMA marks 99349 in that document with a triangle, its symbol for a revised code.
Each phrase in the descriptor controls a different part of the claim, and auditors read the note against each one.
| Descriptor phrase | What it means for billing |
|---|---|
| “Home or residence” | The patient’s private home plus four other residential settings Medicare recognizes: POS 13, 14, 33, and 55 |
| “Established patient” | Professional services from the same physician or qualified health care professional (QHP), or one of the exact same specialty and subspecialty in the same group, within the past three years. NPs and PAs who work with physicians count as the same specialty. |
| “Medically appropriate history and/or examination” | Required in the note at the provider’s judgment; it doesn’t set the level |
| “Moderate level of medical decision making” | Two of the three MDM elements meet or exceed moderate |
| “40 minutes must be met or exceeded” | A minimum, with no upper limit written into the descriptor |
Some references still describe 99349 as moderate to high complexity. That wording traces to the pre-2023 descriptor, which called the usual presenting problems moderate to high severity. The current descriptor says moderate. A visit with high MDM belongs at 99350.
If you’re searching for the CPT code for a home visit with an established patient, 99349 covers the moderate level and three other codes cover the rest. Our home health CPT codes guide maps the full home or residence family next to the G-codes that home health agencies bill.
Yes. CPT 99349 is active for 2026 dates of service. The AMA revised it in 2023 when it merged the home and domiciliary code families, and CMS pays it under the CY 2026 Physician Fee Schedule. Its neighbors in the established patient series, 99347, 99348, and 99350, are active too.
Some older reference PDFs still carry the pre-2023 wording, which required “at least 2 of these 3 key components.” If a 99349 description lists history and exam as components, it predates the 2023 revision. Coders trained on that version may still level home visits by counting exam bullets. Retrain them on MDM and time.
The 2023 merger deleted a group of codes that some charge masters still carry. People still search the 99343 CPT code description three years later. Payers deny CPT code 99343 on any date of service from 2023 on. The 99334 CPT code gets the same treatment.
| Deleted code | What it was | What to bill now |
|---|---|---|
| 99343 | New patient home visit | 99342, 99344, or 99345, based on MDM or time |
| 99324 to 99328 | Domiciliary or rest home visit, new patient | 99341 to 99345 |
| 99334 to 99337 | Domiciliary or rest home visit, established patient | 99347 to 99350 |
| 99339 and 99340 | Domiciliary or home care plan oversight | No one-to-one replacement; Medicare home health plan oversight uses G0181 |
| 99346 | Not a valid home visit code | Nothing; payers reject it as an invalid code |
Pull these codes from your charge master and from any provider pick lists. A new provider in a hurry will pick a deleted code sooner or later if it’s still in a dropdown. You won’t see the denial for weeks.
A home visit qualifies for 99349 when the note supports moderate MDM or at least 40 minutes of total time on the date of the encounter. One pathway is enough. Since 2023, history and exam don’t set the level, although the provider still documents a “medically appropriate” version of each.
For CPT code 99349, the provider picks whichever pathway the note supports better, and the choice can change from visit to visit. A long visit with a stable patient may qualify on time. Short visits often qualify on MDM.
MDM has three elements: the problems addressed, the data reviewed and analyzed, and the risk of patient management. Two of the three must meet or exceed moderate. The AMA’s E/M table for MDM defines each level, and auditors score your note against that table one element at a time.
AMA requirements for moderate medical decision making (two of three elements must meet or exceed moderate)
| Element | What counts as moderate |
|---|---|
| Problems addressed | One or more chronic illnesses with exacerbation, progression, or side effects of treatment; two or more stable chronic illnesses; one undiagnosed new problem with uncertain prognosis; one acute illness with systemic symptoms; or one acute complicated injury |
| Data reviewed and analyzed | One of three categories: (1) any combination of three from review of prior external notes from each unique source, review of the result of each unique test, ordering of each unique test, or assessment requiring an independent historian; (2) independent interpretation of a test performed by another physician or QHP, not billed on its own; (3) discussion of management or test interpretation with an external physician, QHP, or appropriate source, not billed on its own |
| Risk of patient management | Prescription drug management; decision regarding minor surgery with identified patient or procedure risk factors; decision regarding elective major surgery without identified patient or procedure risk factors; or diagnosis or treatment “significantly limited by social determinants of health” |
Take an 82-year-old patient with heart failure whose weight is up four pounds since last week. The provider increases the diuretic and orders a weight recheck in three days. That’s a chronic illness with exacerbation plus prescription drug management. Two elements reach moderate, and a thin data element can’t pull the level down.
One common scoring mistake involves data. Reviewing a single outside record doesn’t meet the moderate data element by itself. Category 1 needs three items in any combination, such as one external note, one lab result, and one test order.
The time requirement for 99349 is 40 minutes or more of total practitioner time on the date of the encounter. Per the 99349 CPT code description time rule, 40 minutes “must be met or exceeded.” That makes 40 a floor. Time-based E/M coding for home visits counts the practitioner’s own work that day, with or without the patient present.
The AMA counts these activities toward total time:
Travel time doesn’t count. The AMA’s guideline reads: “When selecting code level using time, do not count any travel time.” Clinical staff time doesn’t count either, and neither does time spent on another billed service or on another date.
In practice, 99349 covers 40 to 59 minutes, because 60 minutes meets the 99350 threshold. No upper limit appears in the descriptor. A 57-minute visit that stays at moderate complexity still bills as CPT code 99349. Some guides present 40 to 59 minutes as the descriptor’s range; that ceiling comes from the next code’s floor.
Record the time even when the MDM carries the visit. If an auditor scores the MDM one level lower than your provider did, a documented total time can still support 99349. The reverse works too, when a short visit shows clear moderate complexity. A single line at the end of the note covers it:
Total time on the date of service: 46 minutes, including record review, face-to-face evaluation, medication reconciliation with the caregiver, and documentation. Travel time is not included.
Coding 99349-level work as 99348 leaves about $53 per visit behind at the 2026 national Medicare rate. If you’d like a second set of eyes on home visit notes before claims go out, our medical billing services team checks them against the AMA’s MDM table.
The difference between 99348, 99349, and 99350 comes down to MDM level and minimum time. In order, that’s low MDM or 30 minutes, moderate MDM or 40 minutes, and high MDM or 60 minutes. CPT 99349 sits in the middle. Your note has to rule out both neighbors.
Established patient home or residence codes, 2026
| Code | MDM level | Minimum total time | 2026 national Medicare rate (non-QP) | Prolonged add-on |
|---|---|---|---|---|
| 99347 | Straightforward | 20 minutes | $46.09 | None |
| 99348 | Low | 30 minutes | $78.83 | None |
| 99349 | Moderate | 40 minutes | $132.27 | None |
| 99350 | High | 60 minutes | $193.06 | 99417 at 75 minutes or more (CPT payers); G0318 at 110 minutes or more (Medicare) |
E/M times for home codes are minimums, so time alone moves an established visit up a level at each threshold. At the bottom of the series, the 99347 CPT code description covers straightforward MDM or 20 minutes. Prolonged service codes attach to the top level. Our guide to CPT 99417 prolonged services covers the CPT rule.
The 99350 CPT code description matches 99349 except for two points: high MDM and a 60-minute time threshold. High MDM needs two of three elements at high. Examples include a chronic illness with severe exacerbation or a decision about hospitalization.
A patient with a severe COPD exacerbation whose provider weighs hospital admission against treatment at home belongs at CPT code 99350, even at 45 minutes. Time isn’t the deciding factor there. Pick 99350 when the provider’s note documents that level of risk in plain terms.
Low MDM often looks like one stable chronic illness managed at low risk. On time, the range is 30 to 39 minutes. The 99348 CPT code description time rule works the same way as 99349’s, with 30 minutes met or exceeded. A visit under 40 minutes with low MDM stays at CPT code 99348.
Refill visits trip up a lot of coders. Consider a stable hypertensive patient seen for a refill with no dose change. Prescription drug management puts risk at moderate, but the single stable illness keeps problems at low. With one element at moderate, the visit lands at low MDM and bills as 99348.
A patient who hasn’t received services from anyone of the same specialty in your group within three years is a new patient, even at home. New patients use a separate set of home visit CPT codes with longer time thresholds, and 99343 no longer exists in that set.
| Code | MDM level | Minimum total time |
|---|---|---|
| 99341 | Straightforward | 15 minutes |
| 99342 | Low | 30 minutes |
| 99343 | Deleted in 2023 | Not applicable |
| 99344 | Moderate | 60 minutes |
| 99345 | High | 75 minutes |
Medicare accepts 99349 with five place of service codes: 12, 13, 14, 33, and 55, according to Noridian’s home visit guidance. The POS on the claim has to match where the patient lives. Your office address doesn’t matter.
Getting the 99349 CPT code place of service right matters more for audits than for payment. All five settings pay the non-facility rate. A wrong POS inside this group usually doesn’t change the allowed amount, but it does break the match between the claim and the chart.
| POS | Setting | Billing note |
|---|---|---|
| 12 | Home (private residence) | The practitioner has to be in the home for an in-person visit |
| 13 | Assisted living facility | Report the facility address as the service location (Item 32, Loop 2310C) |
| 14 | Group home not licensed as an intermediate care facility for individuals with intellectual disabilities (ICF/IID) | Confirm the home’s licensure |
| 33 | Custodial care facility | A different setting from a nursing facility |
| 55 | Residential substance abuse treatment facility | Often missing from charge templates |
CPT’s definition of home includes temporary lodging such as a hotel or shelter. Medicare’s POS list for this code family doesn’t include POS 16, so check the payer’s policy before you bill a hotel or shelter visit. CPT code 99349 doesn’t cover nursing facility or skilled nursing facility residents.
Before 2023, assisted living visits used the domiciliary and rest home codes, 99324 to 99337. Since January 1, 2023, those visits use 99341 to 99350 with POS 13. Residents of a nursing facility or skilled nursing facility take 99304 to 99310 instead, and our nursing facility code 99306 guide covers that family.
POS errors on home visit claims often start in the practice management system, which fills in POS from the practice location by default. Our POS 12 billing rules guide covers the private home setting in more depth. Watch for these five errors:
Physicians and qualified nonphysician practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists, can bill CPT 99349 under their own NPI. The practitioner has to perform the visit in the patient’s residence. For an in-person visit, Noridian’s guidance says the “physician must be physically present in beneficiary’s home.”
NPPs who bill under their own NPI receive 85% of the Medicare Physician Fee Schedule amount, which puts 99349 at $112.43 before locality adjustment in 2026. State scope of practice and payer credentialing still apply. The rendering NPI on the claim has to belong to the person who did the visit.
Noridian’s Q4 2025 review of 99349 listed “the performing and billing providers are different” among its top three denial reasons. A common cause is a claim billed under the supervising physician’s NPI for a visit an NP did alone. Split or shared billing won’t fix it. CMS limits split or shared visits to facility settings.
Incident-to billing needs direct supervision. In a private residence, that has meant the physician is in the home during the service. CMS’s CY 2026 final rule made virtual direct supervision through live audio and video permanent. The change covers services that require direct supervision, except those with a 010 or 090 global surgery period.
Ask your MAC how it applies that change to incident-to services in a residence. Don’t assume. The Medicare Benefit Policy Manual, Chapter 15, has a narrow general supervision exception for homebound patients in areas with no available home health agency. Noridian’s review flagged claims that “did not support incident-to criteria were met.”
Medicare doesn’t require a patient to be homebound for 99341 to 99350. Noridian’s guidance states: “There is no requirement that patient must be homebound.” Homebound status is a home health benefit rule. For 99349, the note still has to show why the visit happened at home instead of the office.
NPs and PAs who start home visits before their Medicare enrollment or group reassignment clears are a common source of rendering NPI denials. Our credentialing and contracting services team tracks enrollment status so the first home visit claim goes out under an active NPI.
A defensible note for CPT code 99349 answers two questions for an auditor: why the provider saw the patient at home, and what supports the level. It also has to show who did the visit. Miss any of that and an auditor can take the payment back, whatever the quality of the care.
According to CMS E/M compliance tips, incorrect coding caused 49.1% of improper payments for E/M codes in the 2024 reporting period. Insufficient documentation caused 34.1%, and no documentation caused 13.1%. Together, those three causes account for 96.3%.
Noridian’s education for its 99349 review sets out five expectations for medical necessity. Auditors look for each one in the note:
The last item needs a specific reason. A line like “patient uses a walker, can’t manage the clinic stairs, and has no ride” explains the home setting in one sentence. Noridian treats a visit without documented necessity as a social visit, and Medicare doesn’t pay for those.
The 99349 documentation requirements come down to seven items. A coder should find each one without asking the provider a question:
Illustrative example only. It shows how the MDM elements read in a note, and it doesn’t describe a real patient.
CC: Leg swelling and a 2.3 kg (5 lb) weight gain over four days, per the facility weight log.
HPI: 84-year-old with chronic systolic heart failure and CKD stage 3b, seen at her assisted living facility (POS 13). Mild shortness of breath on exertion.
Data: Reviewed facility nursing notes and weight log. Reviewed basic metabolic panel dated September 10, 2026. Ordered repeat BMP.
Assessment: Acute on chronic systolic heart failure with volume overload.
Plan: Increase furosemide from 40 mg daily to 40 mg twice daily. Daily weights. Repeat BMP in five days. Caregiver taught fluid limits.
MDM: Moderate. Chronic illness with exacerbation, three Category 1 data items, prescription drug management.
The visit stays at 99349 because nothing in the note reaches high MDM. If the provider had documented a decision about hospital admission, risk would move to high, and the provider could bill 99350 instead.
Code the condition that drove the MDM first, then the conditions that explain the home setting. These ICD-10-CM codes are valid for FY2026. Confirm each one against the FY2027 code set, which takes effect October 1, 2026.
| ICD-10-CM | Description | Why it fits a 99349 visit |
|---|---|---|
| I50.23 | Acute on chronic systolic (congestive) heart failure | Exacerbation plus drug management |
| J44.1 | Chronic obstructive pulmonary disease with (acute) exacerbation | Exacerbation plus drug management |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia | Therapy adjustment at moderate risk |
| N18.32 | Chronic kidney disease, stage 3b | Drives dosing decisions across the medication list |
| Z74.09 | Other reduced mobility | Supports the reason for a home visit |
| Z59.82 | Transportation insecurity | Supports the home setting and the social determinants risk element |
The 2026 national Medicare payment for CPT code 99349 is $132.27 for clinicians paid at the non-QP conversion factor and $132.93 for qualifying APM participants, before locality adjustment. CMS set two conversion factors for 2026, $33.4009 and $33.5675, and the CMS CY 2026 fact sheet explains the split.
CPT code 99349 RVU breakdown, CY 2026
| Component | Value |
|---|---|
| Work RVU | 2.44 |
| Practice expense RVU (non-facility) | 1.36 |
| Malpractice RVU | 0.16 |
| Total RVU | 3.96 |
| Non-QP payment | 3.96 × $33.4009 = $132.27 |
| QP payment | 3.96 × $33.5675 = $132.93 |
You can confirm these values, and your own locality’s amount, in the CMS PFS Look-up Tool. Our figures come from the April 2026 national relative value file, and CMS updates that file each quarter.
Search results show three national figures for 99349. The $103.21 figure uses 3.09 total RVUs built on a 1.7 work RVU; CMS lists 2.44. A second figure, $122.59, multiplies 3.79 RVUs by $32.3465, which was the 2025 conversion factor. Only $132.27 uses the 2026 values. Check the year and the RVU inputs whenever two published numbers disagree.
Some guides claim home visits pay 60 to 70% more than office visits. That comparison dates to pandemic-era rules and deleted office codes. In 2026, office code 99214 pays $135.61 at the national rate (4.06 RVUs). That’s $3.34 more than 99349, as our 99214 Medicare reimbursement breakdown shows.
Your MAC locality moves the national figure up or down through geographic practice cost indices (GPCIs). Pull your own number from the CMS tool, then apply the NPP reduction when an NP or PA billed the visit. Medicare pays 80% after the Part B deductible, and the patient owes 20% coinsurance.
Medicare Advantage and commercial plans set their own rates, and state Medicaid programs set theirs. The 99349 CPT code reimbursement in those contracts often tracks a percentage of the Medicare rate. Prior authorization and add-on rules differ too. Confirm the plan type before the visit; our insurance eligibility verification team runs that check at scheduling.
Starting January 1, 2026, Medicare pays add-on code G2211 with 99349. The practitioner has to be the continuing focal point for the patient’s care or manage a single serious or complex condition over time. G2211 carries 0.52 RVUs, or $17.37 at the 2026 national non-QP rate.
Paired with 99349, that’s $149.64 per visit before locality adjustment, or $150.39 at the QP rate. The usual Part B deductible and coinsurance apply to G2211. Patients see a small added balance.
CMS describes two situations. In the first, the practitioner is the continuing focal point for all needed services, the way a primary care practice is. The second covers ongoing care for a single serious or complex condition. Home-based primary care fits the first one in most cases.
The CMS G2211 FAQ lists what the record should support: the history of the patient and practitioner relationship, the diagnoses, the assessment and plan, and the other services billed. RHCs and FQHCs don’t get separate payment for G2211. Medicare Advantage plans set their own policies.
Medicare denies G2211 when the base E/M visit carries modifier 25. There’s one exception. If the same practitioner bills an annual wellness visit, a vaccine administration, or any Part B preventive service that day, G2211 still pays. CMS extended that exception to home or residence codes starting January 1, 2026.
| Claim lines | G2211 result |
|---|---|
| 99349-25 + G0439 + G2211 | Payable |
| 99349-25 + minor procedure + G2211 | Denied |
A missing G2211 on an eligible home visit leaves $17.37 behind at the national rate, and it’s easy to miss when providers bill from a home visit template. If you’d like that check built into charge review, our revenue cycle management team adds it as a standing edit.
You can bill 99349 on the same day as an annual wellness visit, advance care planning, vaccines, or a procedure when the note supports a “significant, separately identifiable” visit. In our experience, most same-day problems with CPT code 99349 come from the modifier. Fewer come from the visit itself.
| Modifier | When it belongs on 99349 |
|---|---|
| 25 | A “significant, separately identifiable” visit on the same day as a procedure, AWV, or preventive service, written as 99349-25. It also decides whether G2211 pays. |
| 95 | A visit delivered by telehealth, when the payer requires the modifier. It doesn’t belong on an in-person visit. |
| GV | Hospice patient; the attending physician isn’t employed or paid by the hospice |
| GW | Hospice patient; the service isn’t related to the terminal condition |
Two other modifiers don’t belong on 99349. CMS’s NCCI guidance says not to use modifier 59 on E/M services, since modifier 25 covers a separate E/M visit. Modifier AI applies to initial hospital and nursing facility care, so a home visit doesn’t qualify. Our modifier 59 rules guide explains where 59 does fit.
A home visit that includes an annual wellness visit bills as 99349-25 plus the AWV code when the provider addresses a separate problem. Advance care planning (99497) done during the AWV takes modifier 33, which waives the patient’s cost sharing. Vaccine administration qualifies for the G2211 exception. Our G0439 wellness visit billing guide covers the AWV side.
Chronic care management (99490) can go on a claim in the same month as 99349, as long as the CCM time doesn’t include time spent on the visit. Our chronic care management codes guide covers the monthly time rules.
Transitional care management follows a different rule. The required face-to-face visit is part of 99495 or 99496, so a home visit that counts as that visit doesn’t get its own 99349 line. Later visits in the 30-day period can bill on their own, and our guide to TCM code 99496 covers the timing.
Home health certification (G0180) and recertification (G0179) cover work done without the patient present. Billers on AAPC’s forum report modifier denials when 99349 goes out with G0179. Check the current quarter’s NCCI procedure-to-procedure edit for your date of service before you add a modifier.
Prolonged service codes attach to the highest level in each home series: 99345 for new patients and 99350 for established patients. Some guides say you can add a prolonged code once a 99349 visit runs 15 minutes past 40. Payers won’t pay it. A long visit moves up to 99350 once total time reaches 60 minutes.
Medicare uses its own HCPCS code instead of 99417. The G0318 CPT code description time rule requires 110 minutes with 99350 or 140 minutes with 99345. Medicare counts that time from three days before the visit through seven days after, per the CMS E/M services booklet.
Yes, for Medicare. The CMS telehealth services list for CY 2026 includes 99349 with the action “Maintain.” Medicare patients can receive non-behavioral telehealth at home through December 31, 2027, per HHS telehealth policy updates.
CMS dropped the provisional and permanent labels on the telehealth list for CY 2026, as the CMS CY 2026 rule summary explains. All eight active home or residence codes, 99341 to 99350, appear on that list.
An in-person CPT code 99349 visit still requires the practitioner in the home. A telehealth 99349 follows telehealth billing rules: POS 10 when the patient is at home and POS 02 for other locations, with modifier requirements that vary by payer. Our modifier 95 telehealth rules guide covers the modifier side.
Some billing references say 99349 isn’t on Medicare’s telehealth list; CMS’s own CY 2026 file lists it. Older guides mention the GQ modifier, which applies to asynchronous services in the Alaska and Hawaii federal demonstration programs. Medicaid and commercial plans keep their own telehealth code lists.
99349 draws two kinds of Medicare scrutiny in 2026. Noridian runs a Targeted Probe and Educate (TPE) review of the code in Jurisdiction F, and Recovery Audit Contractor (RAC) reviews flag home visits billed during inpatient stays.
Noridian’s 99349 review results for October 1 to December 31, 2025, listed three top denial reasons. Jurisdiction F covers Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.
| Denial reason | What fixes it |
|---|---|
| Failure to return records | Track each additional documentation request (ADR) and answer by the deadline on the letter, often 45 days |
| Performing and billing providers are different | Bill under the NPI of the person who did the visit, with group reassignment in place |
| Documentation didn’t support incident-to criteria | Confirm supervision rules before billing incident-to in a residence |
The first reason is the easiest to prevent. Noridian denies the claim when the practice misses the ADR deadline, however good the note was. The second is a group practice billing problem at its root: the claim names one provider while the chart shows another.
A TPE round reviews 20 to 40 claims, and a provider can go through up to three rounds with education between each one. CMS gives the provider at least 45 days to improve before the next round, according to the CMS TPE program page.
Noridian refers providers who don’t improve after three rounds to CMS. CMS can then move to 100% prepayment review, extrapolation, a referral to a Recovery Auditor, or other action. Extrapolation applies the error rate from the sample to a larger set of past claims, and CMS recovers the overpayment across that whole set.
RAC topic 0011 is an automated review, approved February 1, 2017, for all A/B MACs, and it lists 99349 as an affected code, per CMS approved RAC topics. Its description reads: “Home Services CPT Codes may not be used for billing services provided in settings other than in the private residence of a beneficiary.”
Under a related topic, 0115, Medicare denies professional claims with a home place of service that overlap an inpatient stay. Some guides say CMS bundles the home visit into the inpatient DRG. The DRG pays the hospital under Part A.
A practitioner who sees an admitted patient bills hospital codes, 99221 to 99223 or 99231 to 99233, with POS 21; our guide to subsequent hospital care codes covers that side. The edits compare dates, so a home visit in the morning and an admission that evening can still trigger a denial. Document both times in the note.
Most 99349 denials we work trace to five causes: wrong POS, modifier errors, NCCI pair edits, missing home-setting necessity, or rendering provider problems. A CPT 99349 denial with CO-58 points to a POS that doesn’t match the setting in most cases.
| Denial code | What it usually means on 99349 | Fix |
|---|---|---|
| CO-58 or RARC M77 | POS doesn’t fit the service | Correct the POS (12, 13, 14, 33, or 55) and resubmit under the payer’s corrected claim process |
| CO-5 | Code doesn’t match the POS, such as POS 11 or 31 | Fix the POS or switch code families |
| CO-4 | Modifier conflict, such as 25 on the wrong line, 59 on an E/M, or 95 on an in-person visit | Correct the modifier |
| CO-236 | NCCI pair edit with a same-day service | Check the edit’s modifier indicator; add 25 only when the visit stands on its own |
| CO-97 | Bundled service, such as a TCM face-to-face visit billed as 99349 | Remove the line or rebill under the right code |
| CO-50 | No documented medical reason for the home visit | Appeal with records, then fix the note template |
| CO-16 with RARC N290 | Rendering provider NPI missing or invalid | Correct the rendering provider |
| CO-B7 | NPP not enrolled for the date of service | Finish enrollment and request a retroactive effective date where the payer allows it |
Fix the root cause before you resubmit. Medicare Part B handles clerical fixes through reopenings. For a Medicare redetermination, the first level of appeal, you have 120 days from the day you receive the initial determination.
Track these denials by code and by rendering provider each month. A pattern that repeats needs a workflow fix, and rebilling alone won’t stop it. That monthly trending is the core of our denial management services work for practices that bill home visits.
Run these seven checks before a 99349 claim leaves the practice. Each one stops a denial reason that shows up on home visit claims.
Print this list as a one-page CPT code 99349 PDF checklist and keep it at the charge review desk. A printed list helps coders who work home visit claims in batches, because the checks are easy to skip when volume spikes.
Once home visit volume outgrows a manual check, our outsourced medical billing team runs these seven checks as claim edits before submission. Misses land in a work queue, where a coder fixes them before the payer sees the claim.
Practices bill 99349 for a moderate-complexity home or residence visit with an established patient. Under the CPT code 99349 description, the visit needs moderate medical decision making or at least 40 minutes of total time on the date of the encounter.
The code covers private homes and four other residential settings: assisted living facilities, group homes, custodial care facilities, and residential substance abuse treatment facilities. Nursing facility residents fall outside it and take 99304 to 99310.
You need 40 minutes or more of total practitioner time on the date of the encounter. The 99349 CPT code description says 40 minutes “must be met or exceeded,” so the descriptor sets a floor with no ceiling. At 60 minutes, time alone supports 99350.
Total time includes record review, the visit, counseling, orders, care coordination, and documentation on that date. Travel time doesn’t count, and neither does clinical staff time or time spent on a service billed on its own.
The 2026 national Medicare amount is $132.27 at the non-QP conversion factor and $132.93 for qualifying APM participants, before locality adjustment. Adding G2211 brings the non-QP total to $149.64. Your MAC locality moves the figure up or down through GPCIs.
NPs and PAs billing under their own NPI get 85% of the fee schedule amount. Once the patient meets the Part B deductible, Medicare pays 80% and the patient owes the other 20%. Commercial and Medicare Advantage rates depend on each contract.
Yes, when the note supports a separate, identifiable visit. Modifier 25 goes on 99349 when you bill it with a procedure or a preventive service such as an annual wellness visit, and NCCI edits decide which pairs Medicare accepts.
G2211 still pays with 99349-25 when the other service is an AWV, a vaccine administration, or a Part B preventive service. Two home visits by the same provider on the same date don’t bill as two codes; combine the work into one visit and level it on the total.
No. 99349 carries a global indicator of XXX in the Medicare Physician Fee Schedule, so global surgery rules don’t apply to it. The visit doesn’t start a postoperative period of its own.
A procedure can still affect the claim. If your provider did a procedure with a 10-day or 90-day global period, a later home visit in that window for an unrelated problem takes modifier 24. Visits for the surgical problem itself stay inside the global package, and the payer won’t pay them as 99349.
Yes. Nurse practitioners can bill 99349 under their own NPI when they perform the visit in the patient’s residence, and the same rule covers physician assistants and clinical nurse specialists. State scope of practice and payer enrollment still apply. Medicare pays them 85% of the fee schedule amount.
The rendering NPI has to match the person who did the visit; Noridian’s 2025 review of 99349 found claims where the performing and billing providers differed. Incident-to billing in a home usually needs direct supervision, so confirm your MAC’s rules first.
No. Medicare doesn’t require homebound status for home or residence visits, and Noridian’s guidance says so in writing. Homebound status belongs to the home health benefit, which pays home health agencies.
For 99349, the note has to show why the provider saw the patient at home instead of the office, such as limited mobility or no reliable transportation. Without that reason in the note, Noridian can deny the claim as a social visit, and a visit for the provider’s convenience doesn’t qualify.
Yes. Since January 1, 2023, assisted living visits use the home or residence codes, 99341 to 99350, with POS 13. The old domiciliary codes, 99324 to 99337, no longer exist, and payers deny claims that still carry them.
Report the facility’s address as the service location in Item 32 of the CMS-1500, which is Loop 2310C on the 837P. If the patient lives in the nursing facility section of a continuing care community, use 99304 to 99310 instead.
Three fixes recover the most money on the home visit claims we review:
A missed G2211 costs $17.37 per visit at the 2026 national rate. Across 200 CPT 99349 visits a month, that’s $3,474 your providers earned and didn’t collect.
If home visits make up a real share of your revenue, ClaimMax RCM can review last quarter’s 99349 claims with your team and show you which ones left money unpaid.
CPT code 73130 reports a radiologic examination of the hand with at least three views. The standard series is posteroanterior (PA), oblique, and lateral. Code from the views in the signed radiology report, not the views on the order. Two views bill 73120.
Billers and practice managers can use this page as a desk reference. You’ll find 2026 CMS rates, modifier rules for the hand X-ray CPT code, bilateral and finger studies, and hospital claims. ICD-10 pairing and the denials our team sees most on hand X-ray remits come last.
| Key Takeaways73130 reports a hand X-ray with at least three views; two views bill 73120, and a single view bills 73120 with modifier 52.Medicare’s 2026 national rate for 73130 is $38.08 global, $8.68 for the professional component (26), and $29.39 for the technical component (TC).Bill 73130 with no component modifier when one practice owns the X-ray unit and reads the films; add 26 or TC only when two entities split the work.Bilateral indicator 3 means each hand pays 100%, so both hands pay $76.16 at the 2026 national rate, billed as RT and LT lines or with modifier 50.NCCI bundles a same-hand finger series (73140) into 73130; on the opposite hand, 73140 pays with RT and LT.Film X-rays (FX) lose 20% of the technical payment, and computed radiography (FY) loses 10%.The October 1, 2026 practitioner MUE for 73130 is three units per date of service, with MAI 3. |
Table of Contents
The CPT code 73130 description reads “Radiologic examination, hand; minimum of 3 views,” and CMS lists the code as active for 2026 with a $38.08 national global rate. Values below come from the October 2026 RVU file (RVU26D), the July 2026 OPPS Addendum B, and the October 1, 2026 NCCI tables.
Table 1. 73130 CPT code description and 2026 CMS indicators
| Field | 2026 value |
|---|---|
| Code | 73130 |
| AMA descriptor | Radiologic examination, hand; minimum of 3 views |
| CMS short descriptor | X-ray exam of hand |
| CPT section | Radiology, Diagnostic Radiology, Upper Extremities (73000 to 73225) |
| Status indicator | A (active code, paid under the PFS) |
| Global period | XXX (global concept doesn’t apply) |
| PC/TC indicator | 1 (splits into 26 and TC) |
| Multiple procedure indicator | 0 (no multiple procedure reduction) |
| Bilateral indicator | 3 (each side paid at 100%) |
| Physician supervision (TC) | 01, general supervision |
| Total RVUs | 1.14 (work 0.17, practice expense 0.95, malpractice 0.02) |
| National rate, non-QP CF $33.4009 | $38.08 global; $8.68 (26); $29.39 (TC) |
| National rate, QP CF $33.5675 (qualifying APM participants) | $38.27 global; $8.73 (26); $29.54 (TC) |
| Change from 2025 | Up 5.1%, from $36.23 on 1.12 RVUs |
| Hospital outpatient (OPPS) | APC 5521, status indicator Q1, $88.91 (July 2026 Addendum B) |
| ASC | Payment indicator N1 (packaged, no separate payment) |
| Practitioner MUE | 3 units, MAI 3 (date of service, clinical), effective October 1, 2026 |
| NCCI PTP with 73140 | 73140 is column two; modifier indicator 1 (v323r0) |
These are national amounts before locality adjustment. Your MAC multiplies each RVU component by its locality GPCI, so your allowed amount for 73130 will land above or below $38.08.
Source: CMS PFS relative value files (RVU26D) and CY 2026 conversion factors; national, before locality adjustment.
CPT code 73130 covers a radiographic study of one hand, including the carpal bones, metacarpals, and phalanges, imaged in three or more projections and read in a written report. It’s a Category I CPT code. Its TC, RT, and LT modifiers come from HCPCS Level II, the other half of the CPT vs HCPCS codes split.
The standard 73130 series is PA, oblique, and lateral, and any three or more documented projections qualify. A fourth or fifth view doesn’t add a unit, so four views still bill one unit of 73130 at the same rate.
Code from the signed report, since the order and the technologist’s worksheet don’t count. If the technologist took three views but the report describes two, the claim goes out as 73120 until the radiologist amends the report. Ask radiologists to state the count and side, as in “three views of the left hand.”
Yes. A three-view 73130 series images all five digits, so a separate finger study of the same hand in the same session doesn’t pay on its own.
A dedicated finger series reports CPT code 73140 (radiologic examination, finger(s), minimum of 2 views). It pays beside 73130 only when it’s on the other hand, and NCCI enforces that split with a PTP edit.
CPT has no thumb-specific X-ray code. A thumb series aimed at the phalanges and the interphalangeal (IP) joint reports the 73140 CPT code, since CPT counts the thumb as a digit. Some payers also want digit modifier FA (left thumb) or F5 (right thumb).
Check the anatomy before you pick the code. If the order and report center on the first metacarpal or the carpometacarpal (CMC) joint, you’re imaging the hand, so 73120 or 73130 applies by view count. Don’t bill a thumb series and a hand series on the same side in one session.
You’ll see 73130 on claims from these seven settings:
These settings don’t use the same modifier, claim form, or payment path. ClaimMax staffs medical billing by specialty for that reason, so an urgent care claim and a radiology read never run through one default setup.
The CPT code for an X-ray of the hand depends on two things: the anatomy in the report and the number of views it documents. CPT hand X-ray coding errors start when someone codes from the order instead. Pull the signed report first.
Table 2. Hand and wrist X-ray codes compared
| Code | Official descriptor | Anatomy | Views | Bill it when |
|---|---|---|---|---|
| 73130 | Radiologic examination, hand; minimum of 3 views | Hand | 3 or more | The report documents three or more hand views |
| 73120 | Radiologic examination, hand; 2 views | Hand | 2 | The report documents two hand views, or one view with modifier 52 |
| 73140 | Radiologic examination, finger(s), minimum of 2 views | Fingers, including the thumb | 2 or more | The study covers digits only, with no hand series on that side |
| 73100 | Radiologic examination, wrist; 2 views | Wrist | 2 | The report documents two wrist views |
| 73110 | Radiologic examination, wrist; complete, minimum of 3 views | Wrist | 3 or more | The report documents a complete wrist series |
| 73092 | Radiologic examination; upper extremity, infant, minimum of 2 views | Whole upper limb, infant | 2 or more | An infant study images the full limb |
| 77072 | Bone age studies | Hand and wrist, skeletal maturity | Per study | The order asks for skeletal maturity only |
| 76140 | Consultation on X-ray examination made elsewhere, written report | Outside films | Not applicable | You read another facility’s films; Medicare lists 76140 as status I (not valid for Medicare), so check payer rules first |
Under the 73140 CPT code description, “finger(s), minimum of 2 views,” the code covers digit studies only, so CPT 73140 can’t stand in for a hand series.
The 73130 CPT code needs three documented views. Two views bill 73120, not 73130-52, because 73120 already describes a two-view study. Modifier 52 on 73130 misreports the service.
One view bills 73120 with modifier 52, since CPT has no single-view hand code. Undercoding costs money too, because 73120 pays $31.40 at the 2026 national rate (0.94 RVUs), $6.68 less than 73130.
A complete wrist series of at least three views bills the 73110 CPT code, and two wrist views bill 73100. If the provider orders the hand and wrist as two studies and the radiologist reports each one, bill both codes with the same laterality modifier.
Medicare’s October 1, 2026 practitioner PTP file (v323r0) carries no edit between 73110 and 73130 in either direction. Commercial scrubbers can still flag the pair, so keep both orders and both reports in the chart.
If films come back negative but snuffbox tenderness persists, the provider may order an MRI to rule out an occult scaphoid fracture. A wrist MRI without contrast bills as a joint study (73221), while non-joint hand anatomy uses 73218. Our guide to upper extremity MRI codes lists the contrast versions of both.
Modifier use on 73130 depends on who owns the equipment, who reads the films, and which hand you imaged. CPT code 73130 needs no modifier when one practice takes and reads the films. Every other 73130 CPT code modifier question comes down to four things: split service, laterality, film or CR equipment, and repeats.
You can send 73130 with no modifier when four facts line up:
Adding 26 to a global claim leaves the $29.39 technical payment unbilled. Nothing on the remit flags the mistake, because the 26 line still pays $8.68.
Split 73130 by who owns the unit and who reads the film:
Table 3. Who bills each 73130 component
| Arrangement | Who bills | Claim form | How 73130 goes out |
|---|---|---|---|
| Practice owns the unit, and its physician reads | Practice | CMS-1500, POS 11 or 20 | 73130, no component modifier |
| Hospital outpatient department takes the films; a radiology group reads | Hospital and radiologist | Hospital: UB-04, bill type 13X. Radiologist: CMS-1500, POS 22 or 19 | Hospital: 73130 under OPPS, no TC modifier. Radiologist: 73130-26 |
| IDTF or imaging center takes the films; an outside radiologist reads | IDTF and radiologist | CMS-1500 for each | IDTF: 73130-TC. Radiologist: 73130-26 |
Chapter 13 of Medicare’s Claims Processing Manual says the interpretation of a diagnostic procedure includes a written report, so a 26 claim needs a signed report on file. Hospitals don’t append TC on the UB-04, because OPPS pays the technical service under the HCPCS code alone.
RT and LT are HCPCS Level II anatomic modifiers, and they don’t change the 73130 payment. Many MACs and commercial payers expect them on extremity imaging, and they keep a same-day second hand from denying as a duplicate. Check each payer’s policy instead of assuming a rule.
Match the side on the modifier to the side in the ICD-10 code, such as M79.641 (pain in right hand) with RT.
FX flags an X-ray taken on film. Medicare cuts the technical component, and the technical portion of a global claim, by 20%, a rule in place since 2017 under the Consolidated Appropriations Act of 2016.
FY flags computed radiography, the cassette-based imaging-plate systems. The FY cut is 10% for 2023 and later, up from 7% for 2018 to 2022. Direct digital radiography takes neither modifier, and the professional component keeps its full $8.68.
Five more modifiers show up on 73130 claims:
The modifier denials we fix on hand X-rays trace back to one setup problem more than any other: a single default modifier applied across every place of service. Our medical billing services team maps each modifier to the billing entity and POS before we submit the claim.
CPT code 73130 carries bilateral indicator 3, so Medicare pays each hand at 100% of the fee schedule, with no bilateral payment reduction. Both hands on one date pay $76.16 at the 2026 national rate (2 × $38.08).
CMS assigns bilateral indicator 3 to radiology procedures and other diagnostic tests that aren’t subject to the bilateral surgery payment rule. Medicare pays each side at the lower of the actual charge or 100% of the fee schedule amount. Indicator 1, the 150% rule for bilateral surgery, doesn’t apply to 73130.
Joint MRI codes such as 73721 carry the same indicator, and our bilateral MRI billing rules walk through that code’s RT and LT setup.
Medicare claim format comes from your MAC. Many MACs ask for 73130-RT and 73130-LT on separate lines with one unit each. Others take 73130-50 on one line with one unit and the charge for both hands.
Before you append CPT 73130 modifier 50, check which format your MAC publishes. Don’t send 73130 with two units on one line and no modifier, since the payer can read it as a duplicate or an MUE problem.
Commercial payers vary more, and many accept 50. If a payer applies a 150% bilateral surgery rule to 73130, compare the remit to your contract and appeal with the CMS indicator.
One hand with three views and the other with two bills 73130-RT and 73120-LT. In the October 1, 2026 PTP file, 73120 sits in column two under 73130 with modifier indicator 1, and RT and LT count as bypass modifiers for that edit.
The practitioner MUE for 73130, effective October 1, 2026, is three units with MUE adjudication indicator (MAI) 3, a clinical date-of-service edit. MAI 3 counts all 73130 lines on the same date together, so the RT line, the LT line, and any repeat film share one limit.
A fourth unit on the same date denies. If the records support the extra films, you can appeal an MAI 3 denial, which a policy-based MAI 2 edit doesn’t allow. CMS posts the current values in the Medicare NCCI MUE tables.
Only when they’re on different hands. CPT code 73130 already images the fingers, so NCCI bundles a same-hand finger series from the same session into the hand study. A hand series on one side and a finger series on the other both pay when you add RT and LT.
CPT 73140 is the column-two code when it pairs with 73130. Medicare’s October 1, 2026 practitioner PTP file (v323r0) lists 73130 in column one and 73140 in column two. The edit carries the rationale “more extensive procedure” and has been in place since October 1, 2003.
Bill 73130 alone. Putting XS or 59 on a same-hand finger study to force payment misstates the service, and auditors look for that pattern.
A finger series, CPT code 73140, on the opposite hand is a different anatomic site. Report 73130-RT and 73140-LT, and add a digit modifier (FA to F9) if the payer asks for one.
The pair carries modifier indicator 1, so an NCCI-associated modifier can bypass the edit when the documentation shows distinct sites. RT, LT, and the digit modifiers all qualify, as our guide to PTP modifier indicators explains. Each side needs its own supporting ICD-10 code.
On a different-hands claim, 73140 adds $39.41 at the 2026 national rate (1.18 RVUs), which is $1.33 more than 73130 itself.
Table 4. When 73130 and 73140 pay together
| Scenario | Bill | Modifiers | Result |
|---|---|---|---|
| Hand series and finger series, same hand, same session | 73130 only | RT or LT per payer | 73140 not payable on its own |
| Hand series right, finger series left | 73130 and 73140 | 73130-RT; 73140-LT, plus a digit modifier if required | Both payable |
| Hand series on both hands, finger series on one | 73130 on two lines | 73130-RT; 73130-LT | 73140 bundles into the same-side hand series |
| Thumb series left, hand series right | 73140 and 73130 | 73140-LT (plus FA if required); 73130-RT | Both payable |
CMS updates the PTP files each quarter, and the Q4 2026 files took effect October 1, 2026. Read the modifier indicator first: 0 means no modifier bypasses the edit, 1 allows a modifier when the services are distinct, and 9 means the edit no longer applies. Pull the pair from the current CMS NCCI procedure-to-procedure edits before you append anything.
If CO-97 or CO-236 keeps landing on hand-and-finger claims, another appeal won’t fix it. Our team runs a denial root-cause analysis that finds the missing scrubber rule, and then we build that rule into your claim edits.
CPT code 73130 pays $38.08 at the 2026 national rate for the global service, $8.68 for the read (26), and $29.39 for the technical component (TC). Any 73130 CPT code reimbursement question starts with the conversion factor, because 2026 has two.
Table 5. 2026 national Medicare rates for 73130, before locality adjustment
| Component | Total RVUs | Non-QP ($33.4009) | QP ($33.5675) |
|---|---|---|---|
| Global | 1.14 | $38.08 | $38.27 |
| Modifier 26 | 0.26 | $8.68 | $8.73 |
| Modifier TC | 0.88 | $29.39 | $29.54 |
The CMS 2026 PFS final rule set both conversion factors. Unless your clinicians are qualifying APM participants (QPs) for 2026, expect the non-QP column on your remits. Added together, the 26 and TC amounts come to $38.07 instead of $38.08 because each one rounds on its own.
Five changes affect 73130 claims in 2026:
Table 6. 2026 national 73130 payment by equipment type
| Equipment | Modifier | TC payment | Global payment |
|---|---|---|---|
| Direct digital radiography | None | $29.39 | $38.08 |
| Computed radiography | FY (10% TC cut) | $26.45 | $35.14 |
| Film | FX (20% TC cut) | $23.51 | $32.20 |
The $8.68 professional component stays the same on all three rows, because the FX and FY cuts apply to the technical side alone. A practice still running CR plates gives up $2.94 per global claim in 2026, and a film unit gives up $5.88.
After the 2026 Part B deductible of $283 (per Medicare.gov), the patient owes 20% coinsurance, which is $7.62 on $38.08. Medicare pays $30.46, before any sequestration reduction. Non-participating providers get an allowed amount of 95%, or $36.18, and the limiting charge caps their bill at $41.60.
Published 73130 rates disagree online because they mix five different numbers:
Commercial rates vary by plan and contract. Each plan posts negotiated rates in its Transparency in Coverage files, and the CMS PFS Look-Up Tool shows your locality’s Medicare figure.
Your posting team either catches FX and FY cuts, locality errors, and TC underpayments or writes them off without knowing it. With our revenue cycle management services, we compare each 73130 payment to its expected 2026 rate and work the short pays.
In a hospital outpatient department, CPT code 73130 splits across two claims. The hospital bills the technical side on the UB-04 under OPPS, and the radiologist bills 73130-26 on the CMS-1500. Neither claim carries the global service.
Set up the facility claim with bill type 13X, then build the line with revenue code 0320 (diagnostic radiology) and HCPCS 73130 plus RT or LT. Leave TC and 26 off the UB-04.
Status indicator Q1 means 73130 packages when the same claim carries a service with status indicator S, T, or V. Closed treatment of a metacarpal fracture (26600) carries status T, so an X-ray on that claim folds into the fracture care payment.
On any other claim, 73130 pays through APC 5521 at $88.91 in the July 2026 Addendum B, posted with the CMS OPPS quarterly addenda. In hospital outpatient billing, the two-view code pays more than the three-view code: 73120 maps to APC 5522 at $106.81. Code the views the report documents, not the ones that pay more.
A $0 line on a Q1 service is packaging, not a denial. Sorting packaged lines from true denials is a routine step in hospital revenue cycle management, and it keeps appeal staff off lines that were never due payment.
The radiologist bills 73130-26 on the CMS-1500 with POS 22 (on-campus outpatient), POS 19 (off-campus outpatient), or POS 23 (emergency department). Our POS 22 billing rules guide covers the on-campus test that separates 22 from 19.
Chapter 13 of the Claims Processing Manual says MACs don’t pay the technical component to a physician for hospital patients, because the hospital receives it under OPPS. At the 2026 national rate, that read pays $8.68.
The diagnosis on a 73130 claim has to support a hand study, name the side, and match the RT or LT modifier. Dates of service on or after October 1, 2026 use the FY 2027 ICD-10-CM set. Each code in Table 7 is valid in that set, per the CMS ICD-10-CM code files.
Table 7. Common ICD-10-CM codes paired with 73130
| Clinical reason | Right hand | Left hand |
|---|---|---|
| Hand pain | M79.641 | M79.642 |
| Joint pain in the hand | M25.541 | M25.542 |
| Finger pain (finger series on that side) | M79.644 | M79.645 |
| Primary osteoarthritis of the hand | M19.041 | M19.042 |
| Primary osteoarthritis of the first CMC joint | M18.11 | M18.12 |
| Rheumatoid arthritis without rheumatoid factor, hand | M06.041 | M06.042 |
| Contusion of the hand, initial encounter | S60.221A | S60.222A |
| Displaced fracture, neck of the fifth metacarpal (boxer’s fracture), initial, closed | S62.336A | S62.337A |
| Fracture of an unspecified phalanx of the thumb, initial, closed | S62.501A | S62.502A |
A left-hand code on a 73130-RT line can deny as CO-11 or CO-4. Unspecified codes such as S62.309A (unspecified fracture of unspecified metacarpal bone) belong on records that don’t name the bone or the side. If the report names the right fifth metacarpal, S62.309A is the wrong code, so query the provider instead of defaulting.
The ICD-10-CM Official Guidelines tell you to report fracture follow-up with the injury code and a 7th character, not an aftercare Z code. Character A covers the period of active treatment, and D covers routine healing after it. Hand fractures in category S62 use these seven values:
A six-week follow-up film of a healing right boxer’s fracture reports S62.336D, and the same film on the left reports S62.337D.
A 73130 claim holds up on review when the report proves the views, the E/M stands on its own, and someone checked the payer’s imaging rules before the visit.
Before you code 73130, confirm the chart has these five items:
Reviewers downcode 73130 to 73120 when the report doesn’t state a view count, so ask radiologists to write the number out.
An office or urgent care E/M and 73130 both pay on the same date. Because an X-ray has no global period (XXX), Medicare doesn’t require modifier 25 on the E/M for it, though some commercial edits still ask for 25.
If the physician bills the interpretation as 73130 or 73130-26, ordering and reviewing that film don’t count toward the visit’s MDM data. Our CPT 99203 MDM rules breakdown covers the rest of the data element for new-patient visits.
Practices that take and read their own films bill a global 73130 beside the E/M. Our full-service medical billing team checks that the visit level still holds without the X-ray data before the claim goes out.
Original Medicare doesn’t require prior authorization for a hand X-ray. The AUC program covered advanced imaging only: CT, MRI, PET, and nuclear medicine. CMS paused it and rescinded its regulations effective January 1, 2024, and it never applied to plain films. Some Medicare Advantage and commercial plans set their own imaging rules, so verify benefits before the visit.
The CPT code 73130 denials we see most start in claim setup: a modifier, a side, or a missing field. Each row below maps to a rule your scrubber can enforce. If the same CARC keeps coming back, our denial management services team finds the missing rule and adds it.
CARC wording in the table follows the X12 claim adjustment reason codes list. CO marks a contractual obligation you can’t bill to the patient, and X12 restricts CARC 18 to group code OA, except where state workers’ compensation rules require CO.
Table 8. CPT 73130 denials: cause and fix
| CARC | What it means | Usual 73130 cause | Fix |
|---|---|---|---|
| CO-4 | The procedure code is inconsistent with the modifier used | A global line billed at a facility POS, or a modifier that doesn’t fit the billing entity | Rebuild the modifier from the billing entity and POS, then resubmit |
| CO-11 | The diagnosis is inconsistent with the procedure | A left-hand diagnosis on an RT line, or a non-hand diagnosis | Recode laterality from the report, then resubmit |
| CO-97 or CO-236 | Included in another service, or incompatible under NCCI | 73140 on the same hand as 73130 | Remove 73140, or document the opposite hand with RT and LT |
| OA-18 | Exact duplicate claim or service | Two 73130 lines without RT and LT, or a resubmission while the original is pending | Add laterality, and check claim status before resubmitting |
| CO-16 | The claim lacks information | Missing laterality, or no ordering provider in Box 17 | Add the missing data and send a new claim |
| CARC 237 with RARC N775 | Legislated or regulatory penalty for an X-ray taken on film | The FX modifier | Not appealable; it’s the statutory 20% TC cut |
Many commercial payers take a corrected claim with frequency code 7, while Medicare Part B MACs handle most fixes through a reopening. If a MAC returns a claim as unprocessable, send a new claim instead of a correction. Box 17 gaps rank among the CMS-1500 form mistakes that trigger CO-16 on diagnostic claims.
Each example shows how the 73130 CPT code goes out on a CMS-1500 line. Put payment modifiers (26, TC, FY, FX) before informational ones (RT, LT, and digit modifiers). Amounts are 2026 national, non-QP.
Table 9. 2026 claim-line examples for 73130
| # | Scenario | POS | Line(s) | ICD-10 | 2026 national amount |
|---|---|---|---|---|---|
| 1 | Urgent care, fall on the right hand, three digital views, contusion | 20 | 73130-RT, 1 unit | S60.221A | $38.08 |
| 2 | Hospital outpatient; radiologist reads a right boxer’s fracture | 22 | 73130-26-RT, 1 unit | S62.336A | $8.68 |
| 3 | Rheumatology office, both hands, RA without rheumatoid factor | 11 | 73130-RT, 1 unit; 73130-LT, 1 unit (some MACs take 73130-50) | M06.041; M06.042 | $76.16 |
| 4 | Hand series on the right; left index finger series | 11 | 73130-RT, 1 unit; 73140-F1, 1 unit (add LT if the payer requires it) | M79.641; M79.645 | $77.49 ($38.08 plus $39.41) |
| 5 | Follow-up of a healing left boxer’s fracture, computed radiography | 11 | 73130-FY-LT, 1 unit | S62.337D | $35.14 |
Box 17 carries the ordering provider’s name on diagnostic claims, with the NPI in 17b. If your scrubber checks indicator 3, the 73140 edit, and laterality, it catches these errors before submission, and it’s the first thing an outsourced medical billing team should build.
ClaimMax RCM is a full-service RCM company headquartered in Sacramento, California, working with practices in all 50 states. Our AAPC-certified coders work inside your existing EHR, and on hand X-ray claims they run four checks:
That’s the routine behind each CPT code 73130 claim we send. If you’d like a second look at your hand X-ray remits, start with a free revenue cycle analysis, and we’ll send a custom report back within 24 hours.
The AMA describes CPT code 73130 as “Radiologic examination, hand; minimum of 3 views.” It covers one hand imaged in three or more projections, with PA, oblique, and lateral as the standard set, plus a written report. Two views report 73120 instead.
Medicare’s 2026 national rate is $38.08 for the global service at the non-QP conversion factor of $33.4009. The read (modifier 26) pays $8.68, and the technical component pays $29.39. Qualifying APM participants receive $38.27. Your MAC’s locality adjustment changes the final amount.
Two views of the hand report 73120. A single view reports 73120 with modifier 52, because CPT has no one-view hand code. Three or more views report 73130. Code from the number of views in the signed report, not the order.
Yes. An office or urgent care visit and a hand X-ray both pay on the same date. Medicare doesn’t require modifier 25 on the E/M because of the X-ray, though some commercial payers’ edits still do. If the physician bills the interpretation, that X-ray can’t also count toward the visit’s MDM data.
Bill one unit per hand. Many MACs want 73130-RT and 73130-LT on separate lines, and some accept 73130-50 on one line. Bilateral indicator 3 means each hand pays 100%, so both hands pay $76.16 at the 2026 national rate.
Original Medicare doesn’t require prior authorization for a hand X-ray, and the AUC program never applied to plain films. CMS paused AUC and rescinded its rules effective January 1, 2024. Some Medicare Advantage and commercial plans set their own imaging rules, so verify benefits before the visit.
