localis

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Q4 2026 takes effect Oct 1, 2026. CMS published it early; dates of service before then are priced under the current release — see the current CPT 78816 rate.

CPT 78816

Whole-Body PET/CT Imaging

Contractor-priced

78816 · PFS Q4 2026 · Upcoming

Contractor-published range

$1,347.74–$2,235.49

Participating · Office (non-facility) · Whole service

MAC-published fee schedules available in Localis: 63 of 144 payment localities. Missing data does not establish a $0 allowance.

No national PFS rate in Q4 2026

Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.

Check for a published amount in your locality.

View contractor sources and effective dates

CMS published status C (carrier-priced) for CPT 78816 in the Q4 2026 Physician Fee Schedule, with no national PFS amount. These figures take effect for dates of service beginning Oct 1, 2026. Treat the blank amount as unpriced, not as $0.

Amount evidence: MAC-published fee schedules and effective dates. The PFS row establishes contractor pricing.

Inspect PFS status evidence
Code
78816
Release
Q4 2026, revision 2
Result
Contractor-priced

Citations

  • Establishes the PFS status (C) and the resulting pathway for this code: contractor-priced.

    Physician relative value file (PPRRVU)

    Q4 2026 · revision 2

    Latest revision of this release

    Release period: October 1 – December 31, 2026

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

    Record details PPRRVU2026_Oct_nonQPP.csv in rvu26d-updated-08-26-2026.zip (row 9,543)
    hcpcs (col 1)
    78816
    modifier (col 2)
    blank
    status_code (col 4)
    C

    SHA-256: 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

    Original source file

Compact facts

Why is there no national PFS amount for 78816?

Its status indicator is C (carrier-priced). Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation. Carrier-priced: no national payment amount.

Payment considerations Copy link

Review the applicable inputs and payment rules. Each link opens the supporting detail on this page.

Professional/technical component Applies NCCI same-day edits Applies Contractor pricing Applies
Other payment indicators (7)

Facility/non-facility: Not determined, Bilateral adjustment: Does not apply, Multiple-procedure reduction: Does not apply, Assistant/co-surgeon treatment: Does not apply, Global surgery: Does not apply, MUE behavior: Not determined, Other fee-schedule routing: Does not apply.

Find the local Medicare amount for 78816 Copy link

Medicare sets this price locally

78816 has no single national Physician Fee Schedule amount. Use the ZIP, modifier, setting, and participation fields above to match it to a Medicare locality and the contractor amount we have on file.

Your practical estimate will appear here

We hold files from First_coast and Noridian and Novitas across JE and JF and JH and JN, most recently effective Jan 1, 2026. A missing locality means our contractor coverage is incomplete—not that Medicare pays $0.

This is the published amount for this code—not necessarily the entire visit or procedure. A hospital may bill a separate facility charge, and other services, drugs, or supplies can add to the total.

Contractor-published source figures, not a national rate. Par = participating-provider amount Non-par = nonparticipating-provider amount C = technical component capped at the OPPS amount # = facility-setting amount
View all 126 published fee rows
Jurisdiction / locality Modifier Note Par Non-par Limiting charge Effective Source
JE · California, Area 05 CMS 01112-05 — C $2,186.83 $2,077.49 $2,389.11 Jan 1, 2026 Contractor file
JE · California, Area 05 CMS 01112-05 -TC C $2,059.62 $1,956.64 $2,250.14 Jan 1, 2026 Contractor file
JE · California, Area 09 CMS 01112-09 — C $2,235.49 $2,123.72 $2,442.28 Jan 1, 2026 Contractor file
JE · California, Area 09 CMS 01112-09 -TC C $2,106.35 $2,001.03 $2,301.18 Jan 1, 2026 Contractor file
JE · California, Area 17 CMS 01182-17 — C $1,843.34 $1,751.17 $2,013.85 Jan 1, 2026 Contractor file
JE · California, Area 17 CMS 01182-17 -TC C $1,726.66 $1,640.33 $1,886.38 Jan 1, 2026 Contractor file
JE · California, Area 18 CMS 01182-18 — C $1,846.06 $1,753.76 $2,016.82 Jan 1, 2026 Contractor file
JE · California, Area 18 CMS 01182-18 -TC C $1,728.14 $1,641.73 $1,887.99 Jan 1, 2026 Contractor file
JE · California, Area 51 CMS 01112-51 — C $2,047.83 $1,945.44 $2,237.26 Jan 1, 2026 Contractor file
JE · California, Area 51 CMS 01112-51 -TC C $1,925.27 $1,829.01 $2,103.36 Jan 1, 2026 Contractor file
JE · California, Area 52 CMS 01112-52 — C $2,186.97 $2,077.62 $2,389.26 Jan 1, 2026 Contractor file
JE · California, Area 52 CMS 01112-52 -TC C $2,059.63 $1,956.65 $2,250.15 Jan 1, 2026 Contractor file
JE · California, Area 53 CMS 01112-53 — C $2,047.62 $1,945.24 $2,237.03 Jan 1, 2026 Contractor file
JE · California, Area 53 CMS 01112-53 -TC C $1,925.25 $1,828.99 $2,103.34 Jan 1, 2026 Contractor file
JE · California, Area 54 CMS 01112-54 — C $1,714.72 $1,628.98 $1,873.33 Jan 1, 2026 Contractor file
JE · California, Area 54 CMS 01112-54 -TC C $1,601.04 $1,520.99 $1,749.14 Jan 1, 2026 Contractor file
JE · California, Area 55 CMS 01112-55 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 55 CMS 01112-55 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 56 CMS 01112-56 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 56 CMS 01112-56 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 57 CMS 01112-57 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 57 CMS 01112-57 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 58 CMS 01112-58 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 58 CMS 01112-58 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 59 CMS 01112-59 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 59 CMS 01112-59 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 60 CMS 01112-60 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 60 CMS 01112-60 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 61 CMS 01112-61 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 61 CMS 01112-61 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 62 CMS 01112-62 — C $1,715.70 $1,629.92 $1,874.41 Jan 1, 2026 Contractor file
JE · California, Area 62 CMS 01112-62 -TC C $1,601.13 $1,521.07 $1,749.23 Jan 1, 2026 Contractor file
JE · California, Area 63 CMS 01112-63 — C $1,815.37 $1,724.60 $1,983.29 Jan 1, 2026 Contractor file
JE · California, Area 63 CMS 01112-63 -TC C $1,698.88 $1,613.94 $1,856.03 Jan 1, 2026 Contractor file
JE · California, Area 64 CMS 01112-64 — C $1,809.02 $1,718.57 $1,976.36 Jan 1, 2026 Contractor file
JE · California, Area 64 CMS 01112-64 -TC C $1,693.04 $1,608.39 $1,849.65 Jan 1, 2026 Contractor file
JE · California, Area 65 CMS 01112-65 — — $2,231.47 $2,119.90 $2,437.89 Jan 1, 2026 Contractor file
JE · California, Area 65 CMS 01112-65 -TC — $2,101.77 $1,996.68 $2,296.18 Jan 1, 2026 Contractor file
JE · California, Area 66 CMS 01112-66 — C $1,891.44 $1,796.87 $2,066.40 Jan 1, 2026 Contractor file
JE · California, Area 66 CMS 01112-66 -TC C $1,774.83 $1,686.09 $1,939.00 Jan 1, 2026 Contractor file
JE · California, Area 67 CMS 01112-67 — C $1,911.50 $1,815.93 $2,088.32 Jan 1, 2026 Contractor file
JE · California, Area 67 CMS 01112-67 -TC C $1,793.82 $1,704.13 $1,959.75 Jan 1, 2026 Contractor file
JE · California, Area 68 CMS 01112-68 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 68 CMS 01112-68 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 69 CMS 01112-69 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 69 CMS 01112-69 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 70 CMS 01112-70 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 70 CMS 01112-70 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 71 CMS 01182-71 — C $1,714.26 $1,628.55 $1,872.83 Jan 1, 2026 Contractor file
JE · California, Area 71 CMS 01182-71 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · California, Area 72 CMS 01182-72 — C $1,863.96 $1,770.76 $2,036.37 Jan 1, 2026 Contractor file
JE · California, Area 72 CMS 01182-72 -TC C $1,747.08 $1,659.73 $1,908.69 Jan 1, 2026 Contractor file
JE · California, Area 73 CMS 01182-73 — C $1,778.15 $1,689.24 $1,942.63 Jan 1, 2026 Contractor file
JE · California, Area 73 CMS 01182-73 -TC C $1,663.83 $1,580.64 $1,817.74 Jan 1, 2026 Contractor file
JE · California, Area 74 CMS 01182-74 — C $1,819.18 $1,728.22 $1,987.45 Jan 1, 2026 Contractor file
JE · California, Area 74 CMS 01182-74 -TC C $1,703.26 $1,618.10 $1,860.82 Jan 1, 2026 Contractor file
JE · California, Area 75 CMS 01112-75 — C $1,714.24 $1,628.53 $1,872.81 Jan 1, 2026 Contractor file
JE · California, Area 75 CMS 01112-75 -TC C $1,601.02 $1,520.97 $1,749.12 Jan 1, 2026 Contractor file
JE · Hawaii, Area 01 CMS 01212-01 — C $1,773.98 $1,685.28 $1,938.07 Jan 1, 2026 Contractor file
JE · Hawaii, Area 01 CMS 01212-01 -TC C $1,660.92 $1,577.87 $1,814.55 Jan 1, 2026 Contractor file
JE · Nevada, Area 00 CMS 01312-00 — C $1,572.94 $1,494.29 $1,718.43 Jan 1, 2026 Contractor file
JE · Nevada, Area 00 CMS 01312-00 -TC C $1,462.36 $1,389.24 $1,597.63 Jan 1, 2026 Contractor file
JF · Alaska, Area 01 CMS 02102-01 — C $1,707.59 $1,622.21 $1,865.54 Jan 1, 2026 Contractor file
JF · Alaska, Area 01 CMS 02102-01 -TC C $1,555.75 $1,477.96 $1,699.65 Jan 1, 2026 Contractor file
JF · Arizona, Area 00 CMS 03102-00 — C $1,525.48 $1,449.21 $1,666.59 Jan 1, 2026 Contractor file
JF · Arizona, Area 00 CMS 03102-00 -TC C $1,415.63 $1,344.85 $1,546.58 Jan 1, 2026 Contractor file
JF · Idaho, Area 00 CMS 02202-00 — C $1,450.98 $1,378.43 $1,585.19 Jan 1, 2026 Contractor file
JF · Idaho, Area 00 CMS 02202-00 -TC C $1,343.93 $1,276.73 $1,468.24 Jan 1, 2026 Contractor file
JF · Montana, Area 01 CMS 03202-01 — — $1,383.36 $1,314.19 $1,511.32 Jan 1, 2026 Contractor file
JF · Montana, Area 01 CMS 03202-01 -TC — $1,272.14 $1,208.53 $1,389.81 Jan 1, 2026 Contractor file
JF · North Dakota, Area 01 CMS 03302-01 — C $1,569.60 $1,491.12 $1,714.79 Jan 1, 2026 Contractor file
JF · North Dakota, Area 01 CMS 03302-01 -TC C $1,460.76 $1,387.72 $1,595.88 Jan 1, 2026 Contractor file
JF · Oregon, Area 01 CMS 02302-01 — C $1,737.36 $1,650.49 $1,898.06 Jan 1, 2026 Contractor file
JF · Oregon, Area 01 CMS 02302-01 -TC C $1,623.00 $1,541.85 $1,773.13 Jan 1, 2026 Contractor file
JF · Oregon, Area 99 CMS 02302-99 — C $1,564.95 $1,486.70 $1,709.71 Jan 1, 2026 Contractor file
JF · Oregon, Area 99 CMS 02302-99 -TC C $1,455.01 $1,382.26 $1,589.60 Jan 1, 2026 Contractor file
JF · South Dakota, Area 02 CMS 03402-02 — C $1,569.30 $1,490.84 $1,714.47 Jan 1, 2026 Contractor file
JF · South Dakota, Area 02 CMS 03402-02 -TC C $1,460.73 $1,387.69 $1,595.84 Jan 1, 2026 Contractor file
JF · Utah, Area 09 CMS 03502-09 — C $1,482.56 $1,408.43 $1,619.69 Jan 1, 2026 Contractor file
JF · Utah, Area 09 CMS 03502-09 -TC C $1,373.28 $1,304.62 $1,500.31 Jan 1, 2026 Contractor file
JF · Washington, Area 02 CMS 02402-02 — C $1,912.86 $1,817.22 $2,089.80 Jan 1, 2026 Contractor file
JF · Washington, Area 02 CMS 02402-02 -TC C $1,792.46 $1,702.84 $1,958.27 Jan 1, 2026 Contractor file
JF · Washington, Area 99 CMS 02402-99 — C $1,650.98 $1,568.43 $1,803.69 Jan 1, 2026 Contractor file
JF · Washington, Area 99 CMS 02402-99 -TC C $1,538.29 $1,461.38 $1,680.59 Jan 1, 2026 Contractor file
JF · Wyoming, Area 21 CMS 03602-21 — C $1,571.05 $1,492.50 $1,716.38 Jan 1, 2026 Contractor file
JF · Wyoming, Area 21 CMS 03602-21 -TC C $1,460.87 $1,387.83 $1,596.00 Jan 1, 2026 Contractor file
JH · Arkansas, Area 13 CMS 07102-13 — — $1,358.72 $1,290.78 $1,484.40 Jan 1, 2026 Contractor file
JH · Arkansas, Area 13 CMS 07102-13 -TC — $1,254.20 $1,191.49 $1,370.21 Jan 1, 2026 Contractor file
JH · Colorado, Area 01 CMS 04112-01 — — $1,646.83 $1,564.49 $1,799.16 Jan 1, 2026 Contractor file
JH · Colorado, Area 01 CMS 04112-01 -TC — $1,535.73 $1,458.94 $1,677.78 Jan 1, 2026 Contractor file
JH · Louisiana, Area 01 CMS 07202-01 — — $1,472.27 $1,398.66 $1,608.46 Jan 1, 2026 Contractor file
JH · Louisiana, Area 01 CMS 07202-01 -TC — $1,363.77 $1,295.58 $1,489.92 Jan 1, 2026 Contractor file
JH · Louisiana, Area 99 CMS 07202-99 — — $1,391.53 $1,321.95 $1,520.24 Jan 1, 2026 Contractor file
JH · Louisiana, Area 99 CMS 07202-99 -TC — $1,284.97 $1,220.72 $1,403.83 Jan 1, 2026 Contractor file
JH · Mississippi, Area 00 CMS 07302-00 — — $1,347.74 $1,280.35 $1,472.40 Jan 1, 2026 Contractor file
JH · Mississippi, Area 00 CMS 07302-00 -TC — $1,242.62 $1,180.49 $1,357.56 Jan 1, 2026 Contractor file
JH · New Mexico, Area 05 CMS 04212-05 — — $1,432.27 $1,360.66 $1,564.76 Jan 1, 2026 Contractor file
JH · New Mexico, Area 05 CMS 04212-05 -TC — $1,324.41 $1,258.19 $1,446.92 Jan 1, 2026 Contractor file
JH · Oklahoma, Area 00 CMS 04312-00 — — $1,405.77 $1,335.48 $1,535.80 Jan 1, 2026 Contractor file
JH · Oklahoma, Area 00 CMS 04312-00 -TC — $1,299.50 $1,234.53 $1,419.71 Jan 1, 2026 Contractor file
JH · Texas, Area 09 CMS 04412-09 — C $1,558.50 $1,480.58 $1,702.67 Jan 1, 2026 Contractor file
JH · Texas, Area 09 CMS 04412-09 -TC C $1,447.74 $1,375.35 $1,581.65 Jan 1, 2026 Contractor file
JH · Texas, Area 11 CMS 04412-11 — C $1,566.35 $1,488.03 $1,711.23 Jan 1, 2026 Contractor file
JH · Texas, Area 11 CMS 04412-11 -TC C $1,455.07 $1,382.32 $1,589.67 Jan 1, 2026 Contractor file
JH · Texas, Area 15 CMS 04412-15 — C $1,561.68 $1,483.60 $1,706.14 Jan 1, 2026 Contractor file
JH · Texas, Area 15 CMS 04412-15 -TC C $1,450.67 $1,378.14 $1,584.86 Jan 1, 2026 Contractor file
JH · Texas, Area 18 CMS 04412-18 — C $1,564.06 $1,485.86 $1,708.74 Jan 1, 2026 Contractor file
JH · Texas, Area 18 CMS 04412-18 -TC C $1,450.86 $1,378.32 $1,585.07 Jan 1, 2026 Contractor file
JH · Texas, Area 20 CMS 04412-20 — — $1,424.05 $1,352.85 $1,555.78 Jan 1, 2026 Contractor file
JH · Texas, Area 20 CMS 04412-20 -TC — $1,317.04 $1,251.19 $1,438.87 Jan 1, 2026 Contractor file
JH · Texas, Area 28 CMS 04412-28 — C $1,551.54 $1,473.96 $1,695.05 Jan 1, 2026 Contractor file
JH · Texas, Area 28 CMS 04412-28 -TC C $1,440.46 $1,368.44 $1,573.71 Jan 1, 2026 Contractor file
JH · Texas, Area 31 CMS 04412-31 — — $1,636.10 $1,554.30 $1,787.45 Jan 1, 2026 Contractor file
JH · Texas, Area 31 CMS 04412-31 -TC — $1,525.55 $1,449.27 $1,666.66 Jan 1, 2026 Contractor file
JH · Texas, Area 99 CMS 04412-99 — — $1,486.32 $1,412.00 $1,623.80 Jan 1, 2026 Contractor file
JH · Texas, Area 99 CMS 04412-99 -TC — $1,378.28 $1,309.37 $1,505.78 Jan 1, 2026 Contractor file
JN · Florida, Area 03 CMS 09102-03 — — $1,567.93 $1,489.53 $1,712.96 Jan 1, 2026 Contractor file
JN · Florida, Area 03 CMS 09102-03 -TC — $1,455.84 $1,383.05 $1,590.51 Jan 1, 2026 Contractor file
JN · Florida, Area 04 CMS 09102-04 — — $1,613.56 $1,532.88 $1,762.81 Jan 1, 2026 Contractor file
JN · Florida, Area 04 CMS 09102-04 -TC — $1,498.36 $1,423.44 $1,636.96 Jan 1, 2026 Contractor file
JN · Florida, Area 99 CMS 09102-99 — — $1,480.80 $1,406.76 $1,617.77 Jan 1, 2026 Contractor file
JN · Florida, Area 99 CMS 09102-99 -TC — $1,371.16 $1,302.60 $1,497.99 Jan 1, 2026 Contractor file
JN · Puerto Rico, Area 20 CMS 09202-20 — — $1,578.48 $1,499.56 $1,724.49 Jan 1, 2026 Contractor file
JN · Puerto Rico, Area 20 CMS 09202-20 -TC — $1,468.71 $1,395.27 $1,604.56 Jan 1, 2026 Contractor file
JN · U.S. Virgin Islands, Area 50 CMS 09202-50 — — $1,578.48 $1,499.56 $1,724.49 Jan 1, 2026 Contractor file
JN · U.S. Virgin Islands, Area 50 CMS 09202-50 -TC — $1,468.71 $1,395.27 $1,604.56 Jan 1, 2026 Contractor file

The authenticated MAC fees API returns the same source rows. ZIP5s that span localities are flagged and use only the crosswalk's dominant locality until ZIP+4 overrides are available.

Reconciling a contractor-priced payment for 78816 Copy link

There is no national allowed amount for 78816, 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 reconcile

  • 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 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.

Nearby payment lines

National Q4 2026 amounts at GPCI 1.000. A blank means this schedule does not publish a payable PFS amount.

Code Why compare Office Facility
78815 Nearby radiology and imaging line in the same release — —
78830 Priced as active rather than carrier-priced $420.85 $420.85
78814 Nearby radiology and imaging line in the same release — —
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 Medicare Claims Processing Manual (Pub. 100-04); 42 USC 1395w-4(i)(2) (SSA §1848(i)(2))—Assistants-at-surgery.

Payment rules

Global period: what 78816's fee already covers Copy link

XXX Does not apply

The global surgery concept does not apply to this code.

Billing policy Copy link

What 78816's billing-policy indicators mean. These show for every code, priced or not: a restriction like "bilateral not allowed" still matters on a carrier-priced code.

Policy Value What it means
Bilateral surgery 0 No bilateral adjustment. The 150% bilateral payment adjustment does not apply to this procedure.
Assistant at surgery 0 Restricted without documentation. Payment for an assistant at surgery is restricted for this procedure unless supporting documentation establishes medical necessity.
Co-surgeons 0 Not permitted. Medicare does not recognize co-surgeons (modifier 62) for this procedure.
Team surgery 0 Not permitted. Medicare does not recognize a surgical team (modifier 66) for this procedure.
Multiple procedures 0 No reduction. No payment reduction applies when this procedure is billed with other procedures on the same date—each is treated as unrelated.
Professional/technical split 1 Splits into professional and technical. This procedure splits into a professional component (modifier 26) and a technical component (modifier TC), each separately payable.

Can you bill it with another code? 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 between it and 78816.

See every current NCCI pair for 78816 →

Billing together (NCCI edits) Copy link

NCCI Q4 2026

Based on CMS's National Correct Coding Initiative (NCCI). A few examples appear here; use the complete edit page to check a specific pair.

Not separately payable with 78816 on the same date of service—no modifier bypasses the edit (modifier indicator 0)

0691T 78816 denies
36591 36591 denies
36592 36592 denies

Showing 3 of 25.

Separately payable with 78816 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)

0558T 0558T denies
0694T 0694T denies
0708T 0708T denies

Showing 3 of 40.

Modifier 59 and the X modifiers are not a universal bypass—CMS expects the most specific applicable modifier, and which one that is depends on the pair and the documented circumstances.

Check a paired code or view all 65 NCCI pairs →

Common payment questions Copy link

Why would a Medicare claim for 78816 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
  • 25 codes form NCCI pairs with 78816 carrying modifier indicator 0—no NCCI-associated modifier bypasses the edit, so billed together on the same date of service, a line of the pair denies. See billing together
  • 40 codes pair with 78816 under modifier indicator 1—separately payable only when an NCCI-associated modifier (59, or a more specific XE, XS, XP, or XU) is clinically appropriate and the documentation supports a distinct service; without one, a line of the pair denies. See billing together
  • 78816 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

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.

History
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 & related

How often 78816 is billed Copy link

Across Original Medicare in CY2024, 78816 ranked #296 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars.

Beneficiaries
85,694
Office + facility patients combined
Services
118,607
Times it was billed
Allowed
$67.6M
Total Medicare allowed dollars
Compare: ↑ #295 more popular · 95816 ↓ #297 less popular · 73221

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 Q4 2026 fee schedule above.

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Source & method

Show sources

Contractor amounts come from the MAC-published schedules and effective dates identified above. The PFS file establishes contractor pricing. Releases are immutable: historical evidence remains tied to the specified release. Our methodology covers the depth: sourcing, parsing, versioning, and how we cross-check claims before they ship.

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 9,543)

Use the (i) buttons next to each amount above for the exact row, columns, and math.

Cite this rate

This citation identifies the source release, so its evidence remains reproducible after a newer release lands.

CPT 78816 National PFS baseline: No national PFS rate (Q4 2026; participating; whole service; GPCI 1.000; sequestration excluded). Localis. https://localishealth.com/cpt/78816/2026/D