CPT 90868
Contractor-priced
90868 · PFS Q1 2013 · Historical
No national PFS rate in Q1 2013
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
Not at a published national rate. CPT 90868 carries status C (carrier-priced) in the Q1 2013 release. Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation. Treat the blank amount as unpriced, not as $0.
PFS status evidence
Inspect PFS status evidence
- Code
- 90868
- Release
- Q1 2013, 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)Q1 2013 · revision 2
Latest revision of this release
Release period: January 1 – March 31, 2013
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
PPRRVU13_V1226_UP0.csv in rvu13ar.zip (row 14,175)- hcpcs (col 1)
- 90868
- modifier (col 2)
- blank
- status_code (col 4)
- C
SHA-256: 79b1988bb9cbab6a61634b6463d26ce88cca431c3e36fa3b73792f29882d95b4
Why is there no national PFS amount for 90868?
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.
Other payment indicators (8)
Facility/non-facility: Not determined, Professional/technical component: Does not apply, Bilateral adjustment: Does not apply, Multiple-procedure reduction: 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.
Reconciling a contractor-priced payment for 90868 Copy link
There is no national allowed amount for 90868, 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.
- Check the visit date: this code carries no follow-up window, so a related visit the day after the procedure is separately payable and should not have bundled.
- Expect an assistant-at-surgery denial here rather than appealing it—a -80 or -AS line on this procedure is never separately payable.
- 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 Q1 2013 amounts at GPCI 1.000. A blank means this schedule does not publish a payable PFS amount.
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.
Global period: what 90868's fee already covers Copy link
The fee covers pre-operative and post-operative work on the day of the procedure only—there is no follow-up window afterward. A visit the next day is separately payable.
| Modifier | Reports |
|---|---|
| -25 | A significant, separately identifiable E/M on the same day as the procedure, beyond its usual pre- and post-operative care. |
A modifier reports what happened; it does not by itself make a service payable. Documentation has to support it.
Billing policy Copy link
What 90868'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 | 1 | Never separately payable. An assistant at surgery may never be separately paid for this procedure—a statutory restriction. |
| 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 | 0 | No PC/TC split. This is a physician service code; the professional/technical split does not apply, and the code is billed as a single service. |
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 90868.
Common payment questions Copy link
Why would a Medicare claim for 90868 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: never separately payable. 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.
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.
How often 90868 is billed Copy link
Across Original Medicare in CY2024, 90868 ranked #324 of the 7,879 CPT codes billed to Medicare that year, by patients served or total allowed dollars. It repeats: a patient billed for it in 2024 was billed 31.5 times on average that year.
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 2013 fee schedule above.
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Source & method
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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.
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 90868 National PFS baseline: No national PFS rate (Q1 2013; participating; whole service; GPCI 1.000; sequestration excluded). Localis. https://localishealth.com/cpt/90868/2013/A