Contractor-priced
0697T · PFS Q2 2023 · Historical
No national PFS rate in Q2 2023
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
PFS status evidence
Inspect PFS status evidence
- Code
- 0697T
- Release
- Q2 2023, revision 1
- Result
- Contractor-priced
Citations
-
Shows this code’s PFS status (C). Result: Contractor-priced.
Physician relative value file (PPRRVU)CMS RVU23BApril 1 – June 30, 2023
This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.
PPRRVU23_APR.csv row 6,172 in rvu23b-updated-02-27-2023.zip
In the CMS file
Loading rows 6,170–6,174 of PPRRVU23_APR.csv…
Download rvu23b-updated-02-27-2023.zip from CMS File fingerprint
6a47fe38620fee5aff0fbba61f50983de3a9733e23acc7373c453261da6f0cd7
CPT 0697T has no published national rate. It carries status C (carrier-priced) in the Q2 2023 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 0697T?
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
CMS indicators that apply to 0697T: PCTC 1 (splits into professional and technical) · MULT PROC 4 (special imaging rules apply).
Splits into professional and technical
PCTC
1
This procedure splits into a professional component (modifier 26) and a technical component (modifier TC), each separately payable.
Special imaging rules apply
MULT PROC
4
This procedure is subject to the diagnostic-imaging multiple-procedure reduction rather than the standard rule.
-51 depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one.
Global surgery period XXX (does not apply).
Why would a Medicare claim for 0697T 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
- 0697T splits into a professional component (modifier 26) and a technical component (modifier TC)—a claim for only one part needs that modifier to price correctly. See billing policy
- Bilateral surgery: no bilateral adjustment. See billing policy
- Assistant at surgery: restricted without documentation. See billing policy
- Co-surgeons: not permitted. See billing policy
- Team surgery: not permitted. See billing policy
- Multiple procedures: special imaging rules apply. 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.
CMS RVU23BApril 1 – June 30, 2023
Can you bill it with another code? Copy link
Reconciling a contractor-priced payment for 0697T Copy link
What to check (5)
There is no national allowed amount for 0697T, 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.
- 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.
- Confirm which component the line carried before comparing anything: the same code prices three ways—globally, as a professional component with modifier 26, and as a technical component with modifier TC.
- Check for a second imaging line on the same date: the technical component of the lower-ranked one is reduced by rule, which accounts for a shortfall that looks like a payer error.
- Check for documentation on file before appealing an assistant-at-surgery denial: payment on the -80 or -AS line is restricted for this procedure unless medical necessity is established.
- 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); CMS Transmittal R694OTN: MPPR on the Technical Component of Certain Diagnostic Imaging Procedures.
Source & method Copy link
The PFS file shows this code is priced by the contractor. Its amounts come from the MAC-published schedules and effective dates shown above.
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01 PPRRVU23_APR.csv · Q2 2023 (RVU23B) · row 6,172—priced by the contractor
- Effective
- April 1 – June 30, 2023
- Locator
- PPRRVU23_APR.csv in rvu23b-updated-02-27-2023.zip · row 6,172 of 18,037 · via CMS
- Fields read
-
Status C (col 4)SHA-256 6a47fe38620fee5a…
Cite this rate
CPT 0697T National PFS baseline: No national PFS rate (Q2 2023; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU23B, PPRRVU23_APR.csv row 6,172. Localis. https://localishealth.com/cpt/0697T/2023/B
Past releases are never edited, so the citation stays checkable after CMS publishes a newer one. Methodology · Plain-text summary · JSON
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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