CPT 61154 Medicare rate in Q1 2024

Rates by locality Copy link

The national baseline uses GPCI 1.000. These locality-adjusted allowed amounts use each payment locality's own GPCIs. Select a state to see its localities.

Look up your exact locality →

Q1 2024 amounts, computed with each locality's own GPCIs, before the ~2% sequestration cut. A state with more than one payment locality shows a range—its tile is colored by the mean across those localities, which is a shading choice, not an amount anyone is paid.

How this amount is computed Copy link

CPT 61154 has a work RVU of 17.07, a non-facility practice expense RVU of 14.97, a facility practice expense RVU of 14.97 and a malpractice RVU of 7.07—for total non-facility RVUs of 39.11 and total facility RVUs of 39.11 in the Q1 2024 release.

The formula is: (work RVU × work GPCI + PE RVU × PE GPCI + MP RVU × MP GPCI) × conversion factor. National amounts use GPCI = 1.000. To price an RVU figure of your own, use the RVU-to-dollars converter.

Every rate combines three parts: work (the clinician’s time, skill and effort), practice expense (office overhead—higher when the service is done in a doctor’s own office), and malpractice (the share of liability-insurance cost). A blank means CMS publishes no national number for that part. Read it as unknown, never as zero.

Who’s billing it Copy link

The allowed amount depends on who bills the service: NPs and PAs get 85% of the fee schedule amount, social workers and counselors 75%. These are national Q1 2024 figures at GPCI 1.000.

There’s no CMS utilization data on file for 61154, so only the physician amounts are shown. Each percentage applies before the 80/20 split and sequestration.

Global period: what 61154's fee already covers Copy link

Major surgery. The fee covers the day before surgery, the day of surgery, and the 90 days after it. Related follow-up care inside that window is not billed separately.

Billing a related follow-up visit inside the 90-day window is the most common way this code gets denied—the payment for that care is already inside the 61154 fee.

A modifier reports what happened; it does not by itself make a service payable. Documentation has to support it.

Billing policy Copy link

These billing-policy indicators explain how 61154 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. See modifier amounts below for the dollar figures these support.

Modifier amounts: -26/TC, -50, -80/81/82, -AS, -62, -66 Copy link

National Office (non-facility) amounts for the modifiers this code's indicators support. These are single-line modifiers only. -51 (multiple-procedure reduction) depends on the other codes on the same claim, so it's a claim-level number rather than a per-code one. Use the calculator for a locality-adjusted, sequestration-aware amount.

Not payable with 61154: -26/TC (professional/technical split); -66 (team surgery).

Each amount applies a standard MPFS percentage (assistant surgeon 16%, non-physician assistant at surgery 13.6%, co-surgeon 62.5%, bilateral 150%) to the national Office (non-facility) amount above. CMS doesn't publish these as a column; Localis derives them, so check them against the current Medicare Claims Processing Manual before relying on them for payment. A row marked If documented carries the ordinary percentage, but this code's CMS indicator allows it only when documentation of medical necessity is submitted. Without that documentation, an unpaid claim is not an underpayment.

CMS RVU24A · January 1 – March 8, 2024 See file rows

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 61154 →

Payment review for 61154 Copy link

Four published payment rules can change what 61154 allows on a claim: facility-only practice-expense pricing, the 90-day global package, the standard multiple-procedure reduction and the 150% bilateral adjustment. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.

Sources: CMS Medicare Physician Fee Schedule Relative Value Files; CMS Practice Expense methodology (cms.gov); CMS Medicare Claims Processing Manual (Pub. 100-04).

Rate history by release Copy link

National Office (non-facility) amount for 61154 across quarterly releases. -0.3% decrease since Q1 2013 · peak $1,347.51 in Q4 2015

Why 61154's rate changed Copy link

National baseline (GPCI 1.000) · Office (non-facility) · Before sequestration

61154's national amount fell $10.20 (−0.8%), from $1,290.83 in Q1 2013 to $1,280.63 in Q1 2024 (from Jan 1). Changes to the conversion factor, which CMS sets for every code, took $48.51 off. CMS revaluing 61154 itself added $38.31: +$31.76 from malpractice RVUs and +$6.55 from practice-expense RVUs. The most recent change came in Q1 2024 (from Jan 1): −$29.79 (−2.3%), with −$44.20 from the conversion factor, +$7.86 from practice-expense RVUs and +$6.55 from malpractice RVUs.

CMS doesn't publish this split; we derive it from each release's RVUs and conversion factor. We apply the new conversion factor to the earlier RVUs first, then price each RVU change at the new conversion factor. Another order would move a few cents between columns, but every total stays the same.

Contracted rate: % of Medicare Copy link

Commercial contracts are often written as a percentage of Medicare ("115% of Medicare"). Enter yours to see what it means for 61154. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $1,280.63 national baseline; the calculator finds that amount from your service ZIP.

See how to find your contract's actual percentage.

How often 61154 is billed Copy link

Across Original Medicare in CY2024, 61154 ranked #1,560 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars.

2024 Medicare fee-for-service national totals. They exclude Medicare Advantage, Medicaid and commercial volume, so real-world use runs higher. This is a calendar-year snapshot from the CMS Physician & Other Practitioners dataset, on a different cycle from the Q1 2024 fee schedule above.

How 61154 compares with other codes Copy link

Against every code with a national PFS amount in Q1 2024 · National baseline · Before sequestration

52.1% Highest vs. lowest locality

61154's Office amount is 52.1% higher in its highest-paid payment locality than in its lowest. That spread is wider than 82% of the 7,283 codes compared; the median spread is 43.0%. How much a code's amount varies by locality depends on its mix of work, practice-expense and malpractice RVUs, since each has its own GPCI.

−0.8% Since Q1 2013

61154's Office amount fell 0.8% from Q1 2013 to Q1 2024. Over the same period, the median code's amount fell 2.4%. That's higher than the change for 66% of the 6,466 codes priced in both releases.

These comparisons cover every code with a national Physician Fee Schedule amount: status A, R or T, with no blank RVUs. The locality comparison leaves out codes with an OPPS cap, because the cap, not the GPCIs, can set their amount in some localities.