Contractor-priced
0494T · PFS Q3 2018 · Historical
No national PFS rate in Q3 2018
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
Check for a published amount in your locality.
PFS status evidence
Inspect PFS status evidence
- Code
- 0494T
- Release
- Q3 2018, revision 1
- Result
- Contractor-priced
Citations
-
Shows this code’s PFS status (C). Result: Contractor-priced.
Physician relative value file (PPRRVU)CMS RVU18CJuly 1 – September 30, 2018
This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.
PPRRVU18_JUL.csv row 5,141 in rvu18c1.zip
In the CMS file
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514e3c115f8e62a35eb5f78fef7ed12ed7b60b22a5fe3f3f1bb5aadf119663c5
CPT 0494T has no published national rate. It carries status C (carrier-priced) in the Q3 2018 release. Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation. The blank amount means unpriced, not $0.
Why is there no national PFS amount for 0494T?
Its status indicator is C (carrier-priced). Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
Which billing rules and modifiers apply? Copy link
Payment rules for 0494T Copy link
Other payment indicators (6)
Why would a Medicare claim for 0494T be denied or paid less?
These come from CMS indicators on this page, not general billing advice.
- Its status indicator is C (carrier-priced)—Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation. See status indicators
- Co-surgeons: payable with documentation. See billing policy
- Team surgery: not permitted. See billing policy
- Multiple procedures: standard reduction applies. See billing policy
Payer-specific coverage and documentation rules live outside these files, so a claim that clears every check here can still be denied on other grounds.
Global period: what 0494T's fee already covers Copy link
The global surgery concept does not apply to this code.
Billing policy Copy link
These billing-policy indicators explain how 0494T is treated. They apply whether the code is nationally priced or carrier-priced: a restriction like "bilateral not allowed" still matters on a carrier-priced code.
| Policy | Value | What it means |
|---|---|---|
| Bilateral surgery | 2 | RVUs already reflect bilateral pricing. The published RVUs already account for a bilateral procedure—no additional bilateral adjustment applies on top of the fee schedule amount. |
| Assistant at surgery | 2 | Payable. An assistant at surgery may be separately paid for this procedure, typically as a percentage of the fee schedule amount. |
| Co-surgeons | 1 | Payable with documentation. Co-surgeons may be paid, but only with supporting documentation establishing the medical necessity of two surgeons. |
| Team surgery | 0 | Not permitted. Medicare does not recognize a surgical team (modifier 66) for this procedure. |
| Multiple procedures | 2 | Standard reduction applies. When billed with other procedures on the same date, the highest-valued one is paid at 100% and the next four at 50% each. |
| Professional/technical split | 0 | No PC/TC split. This is a physician service code; the professional/technical split does not apply, and the code is billed as a single service. |
Can you bill it with another code? Copy link
Check a pair of codes Copy link
Enter a second CPT or HCPCS code billed on the same date of service. We'll check the current NCCI procedure-to-procedure edit for the pair.
Reconciling a contractor-priced payment for 0494T Copy link
There is no national allowed amount for 0494T, so every reconciliation of this line runs against the MAC fee schedule that was in force for the date of service rather than against a national baseline.
What to check
- Compare the paid amount against the MAC fee schedule in force for the date of service; there is no national allowed amount here to reconcile against.
- Rank the claim’s procedure lines before calling a reduced line short-paid—under the standard multiple-procedure rule only the highest-valued one prices in full.
- Check whether a second side was billed separately—the published RVUs already price both sides, so there is no additional amount behind that line.
- Check that any -80 or -AS line was priced from the same release and locality as the primary line; an assistant at surgery prices at a percentage of the fee-schedule amount.
- Reprice the line against the release, locality, setting, modifier and participation status that applied to the date of service before treating any difference as an underpayment.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Medicare Physician Fee Schedule Relative Value Files (status indicator field); CMS Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.
How has it changed? Copy link
When does this rate change?
CMS publishes a fee schedule release every quarter (January, April, July, October), and each is versioned here. See what changed each release, or get an email when a new release moves rates.
Sources: CMS Medicare Physician Fee Schedule Relative Value Files.
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Source & method
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Contractor amounts come from the MAC-published schedules and effective dates shown above. The PFS file shows this code is priced by the contractor. Past releases are never edited, so these sources stay valid after CMS publishes a newer one. Our methodology explains sourcing, parsing, versioning, and how we cross-check claims before we publish them.
Cite this rate
The citation names the release, so anyone can check it even after CMS publishes a newer one.
CPT 0494T National PFS baseline: No national PFS rate (Q3 2018; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU18C, PPRRVU18_JUL.csv row 5,141. Localis. https://localishealth.com/cpt/0494T/2018/C