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CPT 38226 Medicare payment status

Bundled / not separately paid

38226 · PFS Q1 2025 · Historical

Status B is not separately payable under the PFS.

View applicable payment rules
View CMS source and method

CMS RVU25AJanuary 1 – March 31, 2025

PFS status evidence

Physician relative value file (Q1 2025) · rvu25a-updated-01-10-2025.zip (PPRRVU25_JAN.csv row 10,482)
Inspect PFS status evidence
Code
38226
Release
Q1 2025, revision 1
Result
Bundled / not separately paid

Citations

  • Shows this code’s PFS status (B). Result: Bundled / not separately paid.

    Physician relative value file (PPRRVU)CMS RVU25AJanuary 1 – March 31, 2025

    This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.

    PPRRVU25_JAN.csv row 10,482 in rvu25a-updated-01-10-2025.zip

    In the CMS file

    Loading rows 10,480–10,484 of PPRRVU25_JAN.csv…

    Download rvu25a-updated-01-10-2025.zip from CMS File fingerprint c0539b47cbc042fd1b69798e6dd911219f4893bb5be793ae1d1771e7a7151a54

Plain-text summaryReport a problem

CPT 38226 has no published national rate. It carries status B (bundled) in the Q1 2025 release. Medicare folds payment for this code into the service it is incident to, never onto its own line. The blank amount means unpriced, not $0.

Why is there no national PFS amount for 38226?

Its status indicator is B (bundled). Medicare folds payment for this code into the service it is incident to, never onto its own line. Status B is not separately payable under the PFS.

Which billing rules and modifiers apply? Copy link

Payment rules for 38226 Copy link

Other payment indicators (10)
Facility/non-facility: Not determined, Professional/technical component: Does not apply, Bilateral adjustment: Does not apply, Multiple-procedure reduction: Does not apply, Assistant/co-surgeon treatment: Does not apply, Global surgery: Does not apply, NCCI same-day edits: Not determined, MUE behavior: Not determined, Other fee-schedule routing: Does not apply, Contractor pricing: Does not apply.
Why would a Medicare claim for 38226 be denied or paid less?

These come from CMS indicators on this page, not general billing advice.

  • Its status indicator is B (bundled)—Medicare folds payment for this code into the service it is incident to, never onto its own line. See status indicators

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 38226's fee already covers Copy link

XXX Does not apply

The global surgery concept does not apply to this code.

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.

See every current NCCI pair for 38226 →

Why a 38226 line may not pay separately Copy link

CMS publishes no separately payable amount for 38226 in this release, so reconciling the line means establishing which status governed the date of service rather than chasing a fee-schedule difference.

What to check

  • Confirm the status that governed the date of service before working this line as a short payment—CMS publishes no separately payable fee-schedule amount for it in this release.
  • Check the place of service: CMS publishes no Office (non-facility) practice-expense amount for this code, so it prices in a Facility setting only.
  • 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.

Compare against 38225, 38227 and 38228: their amounts are in Related codes.

Check an actual payment Model this code in a contract

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Medicare Physician Fee Schedule Relative Value Files (status indicator field); CMS Practice Expense methodology (cms.gov).

How has it changed? Copy link

Rate history by release Copy link

National Office (non-facility) amount for 38226 across quarterly releases.

Release Status Office Facility
Q4 2026 Oct 1, 2026 – present B — —
Q3 2026 Jul 1, 2026 – Sep 30, 2026 B — —
Q2 2026 Apr 1, 2026 – Jun 30, 2026 B — —
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.

Usage and related codes Copy link

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Source & method

Show sources

This page uses CMS's Medicare Physician Fee Schedule Q1 2025 release (effective January 2025). National baselines use GPCI 1.000 and exclude sequestration. Whether a national amount exists depends on the status and CMS’s payment instructions; blank RVUs are never treated as zero. 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.

Physician relative value file (Q1 2025) · rvu25a-updated-01-10-2025.zip (PPRRVU25_JAN.csv row 10,482)

Cite this rate

The citation names the release, so anyone can check it even after CMS publishes a newer one.

CPT 38226 National PFS baseline: No national PFS rate (Q1 2025; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU25A, PPRRVU25_JAN.csv row 10,482. Localis. https://localishealth.com/cpt/38226/2025/A