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CPT 99254

Unable to determine from available CMS sources

99254 · PFS Q3 2026

Status I is not separately payable under the PFS.

View applicable payment rules
View CMS source and method

Not at a published national rate. CPT 99254 carries status I (not valid) in the Q3 2026 release. Medicare uses a different code to report and pay for this service. Treat the blank amount as unpriced, not as $0.

PFS status evidence

Physician relative value file (Q3 2026) · rvu26c-updated-06-30-2026.zip (PPRRVU2026_Jul_nonQPP.csv row 12,974)
Inspect PFS status evidence
Code
99254
Release
Q3 2026, revision 1
Result
Unable to determine from available CMS sources

Citations

  • Establishes the PFS status (I) and the resulting pathway for this code: unable to determine from available cms sources.

    Physician relative value file (PPRRVU)

    Q3 2026 · revision 1

    Latest revision of this release

    Release period: July 1 – September 30, 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_Jul_nonQPP.csv in rvu26c-updated-06-30-2026.zip (row 12,974)
    hcpcs (col 1)
    99254
    modifier (col 2)
    blank
    status_code (col 4)
    I

    SHA-256: b7d197e73211ef6854c213c267d5fa9dec8df995db8e1ee7d44c0556ad7cee21

    Original source file

Compact facts

Why is there no national PFS amount for 99254?

Its status indicator is I (not valid). Medicare uses a different code to report and pay for this service. Status I is not separately payable under the PFS.

Payment considerations Copy link

Review the applicable inputs and payment rules. Each link opens the supporting detail on this page.

NCCI same-day edits Applies
Other payment indicators (9)

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

Why a 99254 line may not pay separately Copy link

CMS publishes no separately payable amount for 99254 in this release, so reconciling the line means establishing which status governed the date of service rather than chasing a fee-schedule difference.

What to reconcile

  • Confirm the status that governed the date of service before working this line as a short payment—CMS publishes no separately payable fee-schedule amount for it in this release.
  • Check the place of service: CMS publishes no office (non-facility) practice-expense amount for this code, so it prices in a facility setting only.
  • 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 Q3 2026 amounts at GPCI 1.000. A blank means this schedule does not publish a payable PFS amount.

Code Why compare Office Facility
99253 Nearby evaluation and management line in the same release — —
99255 Nearby evaluation and management line in the same release — —
99252 Nearby evaluation and management line in the same release — —
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 Practice Expense methodology (cms.gov).

Payment rules

Global period: what 99254's fee already covers Copy link

XXX Does not apply

The global surgery concept does not apply to this code.

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 99254.

See every current NCCI pair for 99254 →

Billing together (NCCI edits) Copy link

NCCI Q3 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 99254 on the same date of service—no modifier bypasses the edit (modifier indicator 0)

0469T 0469T denies
36591 36591 denies
36592 36592 denies

Showing 3 of 42.

Separately payable with 99254 only when an NCCI-associated modifier is appropriate and documented (modifier indicator 1)

0335T 99254 denies
0338T 99254 denies
0339T 99254 denies

Showing 3 of 5,833.

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 5,875 NCCI pairs →

Common payment questions Copy link

Why would a Medicare claim for 99254 be denied or paid less?

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

  • Its status indicator is I (not valid)—Medicare uses a different code to report and pay for this service. See status indicators
  • 42 codes form NCCI pairs with 99254 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
  • 5833 codes pair with 99254 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

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 99254 across quarterly releases.

Release Status Non-facility Facility
Q4 2026 takes effect Oct 1, 2026 I — —
Q3 2026 Jul 1, 2026 – Sep 30, 2026 I — —
Q2 2026 Apr 1, 2026 – Jun 30, 2026 I — —
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 Q3 2026 release (effective July 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 (Q3 2026) · rvu26c-updated-06-30-2026.zip (PPRRVU2026_Jul_nonQPP.csv row 12,974)

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 99254 National PFS baseline: No national PFS rate (Q3 2026; participating; whole service; GPCI 1.000; sequestration excluded). Localis. https://localishealth.com/cpt/99254/2026/C