Contractor-priced
90868 · PFS Q3 2020 · Historical
No national PFS rate in Q3 2020
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
PFS status evidence
Inspect PFS status evidence
- Code
- 90868
- Release
- Q3 2020, revision 1
- Result
- Contractor-priced
Citations
-
Shows this code’s PFS status (C). Result: Contractor-priced.
Physician relative value file (PPRRVU)CMS RVU20CJuly 1 – September 30, 2020
This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.
PPRRVU20_V0618.csv row 15,756 in rvu20c-updated-06192020.zip
In the CMS file
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ebde66539c09d959dffb822c31f25e7c77955ac2e54e8c120994bef894ac5342
CPT 90868 has no published national rate. It carries status C (carrier-priced) in the Q3 2020 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 90868?
Its status indicator is C (carrier-priced). Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
Payment considerations Copy link
Here are the inputs and payment rules that apply to this code. Each link takes you to the detail below.
Other payment indicators (8)
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.
Which billing rules and modifiers apply? Copy link
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
These billing-policy indicators explain how 90868 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.
| 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 multiple-procedure reduction applies when this procedure is billed with others on the same date; each is paid at its full fee schedule amount. |
| 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
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.
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 check
- 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.
Compare against 90867, 90869 and 90865: their amounts are in Related codes.
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.
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.
Usage and related codes Copy link
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 Q3 2020 fee schedule above.
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Source & method
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Contractor amounts come from the MAC-published schedules and effective dates shown above. The PFS file shows this code is priced by the contractor. 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.
Cite this rate
The citation names the release, so anyone can check it even after CMS publishes a newer one.
CPT 90868 National PFS baseline: No national PFS rate (Q3 2020; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU20C, PPRRVU20_V0618.csv row 15,756. Localis. https://localishealth.com/cpt/90868/2020/C