CPT 96161 Medicare rate in Q1 2021

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 96161. A contract benchmarked to the fee schedule applies it to your locality's allowed amount, not the $2.79 national baseline; the calculator finds that amount from your service ZIP.

See how to find your contract's actual percentage.

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 2021 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 96161 has a work RVU of 0.00, a non-facility practice expense RVU of 0.08, a facility practice expense RVU of 0.08 and a malpractice RVU of 0.00—for total non-facility RVUs of 0.08 and total facility RVUs of 0.08 in the Q1 2021 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.

Global period: what 96161's fee already covers Copy link

This code is always billed alongside another service and carries no follow-up period of its own. The primary procedure's global period governs; this indicator does not determine whether either line is payable.

Billing policy Copy link

These billing-policy indicators explain how 96161 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 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 96161: -26/TC (professional/technical split).

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.

CMS RVU21A · January 1 – March 31, 2021 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 96161 →

Rate history by release Copy link

National Office (non-facility) amount for 96161 across quarterly releases. -28.5% decrease since Q1 2017 · peak $4.67 in Q1 2017

Why 96161's rate changed Copy link

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

96161's national amount fell $1.88 (−40.3%), from $4.67 in Q1 2017 to $2.79 in Q1 2021. Changes to the conversion factor, which CMS sets for every code, took $0.13 off. CMS revaluing 96161 itself took $1.75 off: −$1.75 from practice-expense RVUs. The most recent change came in Q1 2021: +$0.26 (+10.3%), with +$0.34 from practice-expense RVUs and −$0.08 from the conversion factor.

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.

How often 96161 is billed Copy link

Across Original Medicare in CY2024, 96161 ranked #3,275 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 2.3 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 2021 fee schedule above.

How 96161 compares with other codes Copy link

Against every code with a national PFS amount in Q1 2021 · National baseline · Before sequestration

64.3% Highest vs. lowest locality

96161's Office amount is 64.3% higher in its highest-paid payment locality than in its lowest. That spread is wider than 97% of the 7,193 codes compared; the median spread is 45.2%. 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.

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.