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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 97546 rate.

CPT 97546

Restricted / special payment rules

97546 · PFS Q4 2026 · Upcoming

No national PFS rate in Q4 2026

Status R: no national PFS amount. The RVUs for this setting are all zero; they do not establish a $0 allowance. Special payment instructions apply.

View applicable payment rules
View CMS source and method

CMS published status R (restricted) for CPT 97546 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.

PFS status evidence

Physician relative value file (Q4 2026) · rvu26d-updated-08-26-2026.zip (PPRRVU2026_Oct_nonQPP.csv row 12,895)
Inspect PFS status evidence
Code
97546
Release
Q4 2026, revision 2
Result
Restricted / special payment rules

Citations

  • Establishes the PFS status (R) and the resulting pathway for this code: restricted / special payment rules.

    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 12,895)
    hcpcs (col 1)
    97546
    modifier (col 2)
    blank
    status_code (col 4)
    R
    work_rvu (col 6)
    0
    pe_rvu_nonfacility (col 7)
    0
    pe_rvu_facility (col 9)
    0
    mp_rvu (col 11)
    0

    SHA-256: 4d0d3f19bd954ffc0f5b8439169d267da023d4f6911f4539bb6e98723cb1a626

    Original source file

Compact facts

Why is there no national PFS amount for 97546?

Its status indicator is R (restricted). Special coverage instructions apply, so whether Medicare pays depends on the circumstances of the service. Status R: no national PFS amount. The RVUs for this setting are all zero; they do not establish a $0 allowance. Special payment instructions apply.

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
Other payment indicators (8)

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

Payment review for 97546 Copy link

Three published payment rules can change what 97546 allows on a claim: status R coverage instructions, add-on billing and documentation-restricted assistant-at-surgery payment. Each is a legitimate reason for a paid amount to differ from the fee-schedule amount on this page.

What to reconcile

  • Treat the published amount as conditional—status R carries special coverage instructions, so a payable fee-schedule amount does not by itself establish that this line should have paid.
  • Reconcile this line together with the primary procedure on the same claim—it is an add-on that is never billed alone and carries no global period of its own.
  • 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
97545 Does not apply global period rather than add-on code — —
97597 Priced as active rather than restricted $101.54 $31.06
97542 Priced as active rather than restricted $31.06 $31.06
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 97546's fee already covers Copy link

ZZZ Add-on code

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

What 97546'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 7 Value 7. Indicator value not recognized.

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 97546.

See every current NCCI pair for 97546 →

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 97546 on the same date of service—no modifier bypasses the edit (modifier indicator 0)

36591 36591 denies
36592 36592 denies
96523 96523 denies

Separately payable with 97546 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)

G0151 97546 denies
G0157 97546 denies
G0159 97546 denies

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 6 NCCI pairs →

Common payment questions Copy link

Why would a Medicare claim for 97546 be denied or paid less?

These come from CMS indicators on this page, not general billing advice.

  • Its status indicator is R (restricted)—Special coverage instructions apply, so whether Medicare pays depends on the circumstances of the service. See status indicators
  • 3 codes form NCCI pairs with 97546 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
  • 3 codes pair with 97546 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
  • 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

Rate history by release Copy link

National non-facility amount for 97546 across quarterly releases.

Release Status Non-facility Facility
Q4 2026 takes effect Oct 1, 2026 R — —
Q3 2026 Jul 1, 2026 – Sep 30, 2026 R — —
Q2 2026 Apr 1, 2026 – Jun 30, 2026 R — —
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

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Source & method

Show sources

This page uses CMS's Medicare Physician Fee Schedule Q4 2026 release (effective October 2026). National baselines use GPCI 1.000 and exclude sequestration. Status and payment instructions determine whether a national amount is established; blank RVUs stay blank. 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 12,895)

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 97546 National PFS baseline: No national PFS rate (Q4 2026; participating; whole service; GPCI 1.000; sequestration excluded). Localis. https://localishealth.com/cpt/97546/2026/D