Contractor-priced
0816T · PFS Q3 2024 · Historical
No national PFS rate in Q3 2024
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
PFS status evidence
Inspect PFS status evidence
- Code
- 0816T
- Release
- Q3 2024, revision 1
- Result
- Contractor-priced
Citations
-
Shows this code’s PFS status (C). Result: Contractor-priced.
Physician relative value file (PPRRVU)CMS RVU24CJuly 1 – September 30, 2024
This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.
PPRRVU24_JUL.csv row 6,725 in rvu24c-updated-09-09-2024.zip
In the CMS file
Loading rows 6,723–6,727 of PPRRVU24_JUL.csv…
Download rvu24c-updated-09-09-2024.zip from CMS File fingerprint
63e2b9617ccd91e8ad68d5f23a0ae26a106d0cdfdf6390631fbac7b7e0513df1
CPT 0816T has no published national rate. It carries status C (carrier-priced) in the Q3 2024 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 0816T?
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 0816T: GLOB DAYS YYY (contractor decides) · MULT PROC 2 (standard reduction applies).
Contractor decides
GLOB DAYS
YYY
Your Medicare Administrative Contractor decides whether a global period applies and sets its length when it prices the code. The result is 0, 10, or 90 days.
Standard reduction applies
MULT PROC
2
When billed with other procedures on the same date, the highest-valued one is paid at 100% and the next four at 50% each.
-51 depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one.
Why would a Medicare claim for 0816T 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
- 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: 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.
CMS RVU24CJuly 1 – September 30, 2024
Can you bill it with another code? Copy link
Reconciling a contractor-priced payment for 0816T Copy link
What to check (5)
There is no national allowed amount for 0816T, 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.
- Ask the MAC which global period it assigned: the contractor sets the follow-up window for this code, so whether a post-operative visit should have paid depends on the contractor that priced it.
- 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 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); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.
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.
-
01 PPRRVU24_JUL.csv · Q3 2024 (RVU24C) · row 6,725—priced by the contractor
- Effective
- July 1 – September 30, 2024
- Locator
- PPRRVU24_JUL.csv in rvu24c-updated-09-09-2024.zip · row 6,725 of 18,664 · via CMS
- Fields read
-
Status C (col 4)SHA-256 63e2b9617ccd91e8…
Cite this rate
CPT 0816T National PFS baseline: No national PFS rate (Q3 2024; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU24C, PPRRVU24_JUL.csv row 6,725. Localis. https://localishealth.com/cpt/0816T/2024/C
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.
Did this answer your question about CPT 0816T?
Tell us what you were trying to work out and we'll answer you or build the page that does.