Contractor-priced
95199 · PFS Q2 2016 · Historical
No national PFS rate in Q2 2016
Your Medicare Administrative Contractor prices this code case by case, usually after reviewing documentation.
Check for a published amount in your locality.
PFS status evidence
Inspect PFS status evidence
- Code
- 95199
- Release
- Q2 2016, revision 1
- Result
- Contractor-priced
Citations
-
Shows this code’s PFS status (C). Result: Contractor-priced.
Physician relative value file (PPRRVU)CMS RVU16BApril 1 – June 30, 2016
This PFS record alone does not establish a $0 allowance or a coverage determination. Any amount from another schedule needs its own evidence.
PPRRVU16_April_V0202.csv row 15,688 in rvu16b.zip
In the CMS file
Loading rows 15,686–15,690 of PPRRVU16_April_V0202.csv…
Download rvu16b.zip from CMS File fingerprint
a6f009bac8359a1f7d870e6b668dd2e69d1658423373dbb0ca0c267cdae773b9
CPT 95199 has no published national rate. It carries status C (carrier-priced) in the Q2 2016 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 95199?
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 (9)
Why would a Medicare claim for 95199 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: 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.
Which billing rules and modifiers apply? Copy link
Global period: what 95199's fee already covers Copy link
The global surgery concept does not apply to this code.
Billing policy Copy link
These billing-policy indicators explain how 95199 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 | 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 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 95199 Copy link
There is no national allowed amount for 95199, 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 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.
Compare against 95180, 95170 and 95250: 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); 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
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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 95199 National PFS baseline: No national PFS rate (Q2 2016; participating physician; whole service; GPCI 1.000; sequestration excluded). CMS RVU16B, PPRRVU16_April_V0202.csv row 15,688. Localis. https://localishealth.com/cpt/95199/2016/B